Good evening, everybody. Good morning. Good afternoon, depending on where you're joining us from. My name is Gregory Greco. I am the immediate past president of the American Society of Plastic Surgeons, and I want to welcome you tonight to our webinar. This is the webinar. It's a very exciting topic. We have some great experts to talk about chin correction. We're going to be talking about alloplastic osteotomy, chin correction, as well as fat transfer and the use of fillers. There is a Q&A question. Okay, great. Yeah. So if you look at the bottom of your screen, there's a Q&A button. So we would love to hear from you. Feel free to type your questions at the bottom. The way tonight's webinar is going to work is we're going to have three presentations. They're each going to be 15 minutes each, and then we'll have the opportunity for a good 15-minute Q&A at the end. So please feel free. We're certainly not going to be able to get through every question, but we're going to go through and hopefully we'll leave you with a lot of great information. This will be a recorded seminar, so if you missed it tonight or if you want to go back and watch it, it will be on our ASPS EdNet, so you're welcome to go and look at the information and watch the webinar. So if you don't have the opportunity to watch it based on where you are. So without further ado, I'd love to get started. I want to introduce you to our esteemed faculty and panelists tonight. We have Dr. Usha Rajagopal, who's going to be speaking to us, Dr. Jacques Saboy, and Dr. Bahman Ghairan. Tonight we're going to start with Dr. Jacques Saboy. He's a board-certified plastic surgeon in France, and he's a specialist in craniofacial surgery, cleft lip and palate surgery, and aesthetic facial surgery. He's the past president of the French Society of Plastic Surgery, and is currently the general secretary. Dr. Saboy, thank you for joining us tonight, and we look forward to your presentation. Without further ado, thank you. Thank you very much, Gregory, for your kind invitation. This presentation is about the aesthetic results of genioplasty, but also the functional improvement we can obtain in terms of labial competency. The shin-wing technique is an unusual osteotomy of the lower part of the mandible that allows important movements of the chin. So first, next please, what is lip competency? It's an upper and lower lip contact on the wrist without muscle contraction, without any effort. It's a permanent barrier between ambient air and oral cavity. The consequences of lip incompetency are first functional, lip dryness, dry mouth, night thirst, mouth closing by contraction of mental muscle, but also aesthetic consequences, at rest, exposure of teeth, and gentler smile, false labial occlusion with a flat chin contracted and the lower lip raised. On this profile, you can see that the labial occlusion is made by contraction of the mentalist muscle, and you see this aspect flat of the chin. Ear face, exactly the same problem with the contraction of the mentalist muscle and the aspect really flat of the chin. The etiologies of this lip incompetency are maxillomandibular disorder and insufficient chin like on the right, the guy on the right. Some girls, the same with maxillomandibular disorder, insufficient chin in the middle. I was used to do a classical genioplasty with a horizontal section and put forward the bone, the chin bone, and put a mini plate, but the problem is that sometimes I have lateral holes. This is a negative point. On the next, you see on the face, this aspect of lateral holes because there is not enough bone going forward. So I decided to change, and I met Dr. Albino Triaca in Zurich, who first described this chin wing genioplasty, the name is from him, in 2010. He described this technique with a section of all the lower part of the mandible and put everything forward from the anterior part to the angles, but I saw that the angles are not, sometimes you don't need to cut the angles. So that's the next. I decided to do something shorter. So I did a short chin wing genioplasty. So it's the same osteotomy, but without cutting the angles. Now the technique, first I do an incision by the teeth and tooth by tooth. I open the mucosa. You see, I go through the mucosa, next, and I will, like that, go by the teeth and open everything to the bone, just in front, next. You see here, and I go down, but I stop at the end of the anterior part. I don't go back because I need vascularization of the bone. And if I open everything back, I have no more vascularization, next. We respect the chin nerve, both parts, and we can dissect a little to have a better movement on the nerve and to protect him, yes, next. Then I draw a blue mark, and I have three lines, one in the middle and two in front of the canines, so I know exactly where I have to change my direction of the section. You will see now. In the anterior part, I do a vertical section in front of the incisors to the canines. Here with the bone cutter, I will cut directly vertically, not horizontally like in the past technique, yes, next. So now I have cut everything vertical, yes, next. Like you see in the drawing, vertically like that. And then I will cut obliquely. So this, here you see the protection of the nerve, so I don't damage the nerve, yes. And here I cut in an oblique way, direction, yes. And you see here now I have cut the bone front, laterally, so I can move forward all the lower part of the chin and the lateral part of the mandibula, yes. Here you see the nerve, and we have now a hole, a gap between these two parts. And here inside, I will put graft. So first of all, I put the mini plate, and it's 6 millimeters, 8 millimeters, 10 or 12. I have four plates, one in the middle, and two lateral. Here, one on the left, another one on the next, one on the right. Once these three plates and screws are in place, I use triclosum phosphate. And I will use also platelet-rich factor, yes. You are used to this technique, and the fluid is put with the triclosum phosphate. I mix it, and I will use some membrane to protect this graft, yes. Here on the platelet-rich fibrin, I will do some four membranes, yes. And the PL fluid is made with, is joined with the triclosum phosphate. Then I will put it inside, inside the gap. So now, it's everything closed like a sandwich. I prefer to put it inside. You know that all the graft, opposition grafts are not really good, but like a sandwich like that is really good because we have bone on one side and bone on the other side. So every time, the bone is really, the ossification is really good. The grafting with triclosum phosphate. The membrane just in front, and now I can suture and close everything like that. And I have no incision, no incision, no scar inside the vestibule, nothing. Yes, so I will show you some cases of chin wing. Here a little girl with labial incompetency and the chin back. Now, just before and after, yeah. The profile, yeah, you can change. And you have no holes, lateral holes, because we go backward to take the bone, not like in the classical one. Yeah, it's a radial. And after, just after surgery, you can see the phosphatidyl-calcic, and six, eight months later, you see the ossification. And now we see some more cases. Another girl, profile, lateral view, and the radial. The same, just in front, and the mini plates, and the bone. Other cases, you can go now, yes. The young guy, profile. You see the labial competency, every time is better, every time. Because we move forward, all the tissue, muscles, skin, everything is going up and coming with, because we don't separate the bone for all the lower part, because we need vascularization. Just the anterior part is removed from the bone, but everything is coming with the bone. It's not some osteotomy, some genioplasty, where you cut everything, you move, and you put your, no, here, you just cut the bone, and you move everything forward. Sometimes, we use this chin wing technique with other osteotomies. Here, you will see some cases of maxillary osteotomy, like an open bite, or you can perform a maxillary surgery, and the chin wing at the same time. Both surgery. Here are some cases of maxillary and chin wing. Another case, expansion of the maxillary and chin wing. And you see this chin flats, and after surgery, no more. Here's the same. Sometimes, mandibular osteotomy, an advancement of the mandibular, and a chin wing. Case here, on the profile, the lower part. Here's the same advancement of the mandibular and chin wing, and the labial competency again. It's really these both improvements, aesthetic and functional. Also, we can do a bimaxillary osteotomy, maxillary and mandibular, and chin wing, so we can perform everything at the same time. Here, on the radio, you see the maxillary, the mandibular, and the chin wing. Another case, before and after. Before and after. Again, the labial competency. So, in conclusion, I think that the chin wing genioplasty is an osteotomy of the lower part of the jaw, with a good respect of the chin nerve, if you do everything like you need. That needs bone graft, and I put 3-phosphatic acetic inside, like a sandwich. I put membranes to protect the 3-phosphatic acetic. The advancement is between 6 and 12 millimeters, usually, without any scar, and with aesthetic and functional results. Yes, so, thank you very much for your attention. Jacques, thank you so much for that unbelievable presentation, really beautiful results, and I'm looking forward to the Q&A session. So, the next speaker is Dr. Raja Upal, Usha Raja Upal, and she's joining us from San Francisco. She's a board-certified plastic surgeon and the medical director of the San Francisco Plastic Surgery and Laser Center. She specializes in cosmetic surgery of the face, breast, and body, and her practice is a premier center for cosmetic dermatology, medical skincare, and laser treatments. For the past decade, Dr. Raja Upal has been invited to present national conferences and has served as a trainer for advanced injectable and surgical techniques. She recently published articles on non-surgical rhinoplasty and thread lifts for the face in the latest volumes and advances in cosmetic surgery. She's appeared in Glamour, W Magazine, New York Post, Forbes, Huffington Post, and Beauty, and Harper's Bazaar. I welcome Dr. Raja Upal, and she's going to be speaking to us on chin fillers. Thank you, Dr. Raja Upal. My name is Usha Raja Upal. I'm in solo private practice in San Francisco, and today I'm going to be talking about fillers for the chin and jawline area. I have my information on my Instagram and website. You can certainly email me or message me if you have any questions. These are my disclosures. I have been a trainer for Allergan. I have some Abibi stock, and I'm going to talk about some of these products, but my opinions are my own. Good candidates are patients seeking non-surgical options to improve the lower face, so for chin and jawline area. They say they want to be more beautiful or attractive, and certainly they're looking for symmetry, balance, and softness and smoothness. These are great candidates for the non-surgical options. So my protocol, certainly everyone has an informed consent signed. Again, I'm going to stress it's very important to add the informed consent, the rare occurrences of tissue necrosis, vascular compromise, blindness, stroke, etc. I do take good photographs, both in repose and smiling. When the patient comes in, we do topical numbing, and then in 15 to 20 minutes, wipe off the topical numbing, have them ice the area, then I start my injections. My protocol, nearly all the time, I will blend the product. If it's an HA product, I do that, or a calcium hydroxyapatite, I blend it, but I always blend it with normal saline and with the radius with some lidocaine epinephrine. I use both the needle and candida. Again, this is again to stress the informed consent is complete. And also, I have an emergency protocol in place because I do do a lot of fillers. I do have nurses in my office also do fillers. So we have an emergency protocol in place. All the injectors are familiar with this, and we also review this emergency protocol every quarter, just like you would do for surgery. I do have an adequate supply of hyaluronidase at all times. I usually have a minimum of eight vials of hyaluronidase in the refrigerator. And then we have a kit, a little emergency kit that has aspirin in it. We have some nitro paste and Keflex in case you want to prophylactically treat someone if I think they have a vascular occlusion. We do have Pronox that can help dilate blood vessels and have the hyaluronidase get to that area faster if you have a vascular occlusion. Cetazolamide to reduce intraocular pressure in case they have any visual disturbances. We have a place where we could send patients to for hyperbaric oxygen treatment if they have any issues with tissue compromise. Other things that can help are Timalox to reduce intraocular pressure. Really important to have an ophthalmologist number who would know how to deal with this if you had any issues with visual problems after the treatment. And certainly nowadays, it's something to consider is to have access to high quality ultrasound device and know how to use it. I actually have a really good ultrasound that can identify vasculature of the face in the office. The fillers I commonly use are hyaluronic acid products, and I use many different types and formulations of this. I also use calcium hydroxyapatite. I also on occasion use PMMA. And it really depends on what the area of treatment and also patient choice. And like I said, I always like to blend the filler. Filler, I feel like there's less injection pressure when I'm injecting a blended filler such that even if I were to get into a vessel, there'll be less product injected into the vessel and the product is going to be injected with much less force. So a good rule of thumb is when you're injecting someone is not to be looking at your syringe as to how much you're injecting, but really looking at the patient and the skin surrounding the area to make sure there's no blanching and then the patient is comfortable and not really in pain. In this slide, you see the vascular anatomy. Some of it certainly is very predictable. And today we're talking about the chin and jawline area. So certainly areas that come into play and arteries that come into play are the patient artery getting into the interlabial artery. There's a mental artery, and there's also a tiny little submental artery that we need to be careful about. These come off the external carotid. You've probably seen this slide before. It talks about high risk injection areas. The chin and jawline are considered a lower risk injection area, but it's really important to be cognizant of all the things we talked about, the arterial vascular anatomy, and be really careful with injections. These are some examples of my patients that I've injected. This is a 31-year-old woman, and then we treated her with three syringes of Radiesse, that's Caja, both to her chin and the angle of her jaw. You'll notice how well her chin projection is. She has nice balance from the nose, lips to her chin. And also, if you look at her jawline, she has a nice snatched jawline now. She's had no other treatments such as Lipo or Kybella, et cetera, for her submental area. There's another patient, there's a very popular procedure in our office where it's called, especially with the Asian patients, where they want a V-line to the chin area. So instead of being a flat or rounded chin, they want more of a V-line structure. And so this is a woman in her mid-twenties, and I had done some Juvederm to her chin to give her the nice V-line. And so in this patient, we actually used filler, both to enhance her nasal proportions and chin. And so it really gives her a very well-balanced profile view. She's in her mid-twenties. She's had, I usually use Restylane L for the nose, so Restylane for the nose. And then in her chin, she had two cc's of Juvederm Ultra for her chin. And you can see how great her profile view is. Another patient, a little older, she's 61. She's got a lot of right tits. So for her, in the perioral chin area, she had two syringes of Vobella for the perioral lines and a small amount in her lip. And then she had Juvederm Ultra, again, for the pre-gel sulcus area and some Voluma for the jawline area. So you can get a real nice smoothing and effect of the face softening, smoothing of right tits and much better balance and decreases the signs of aging. Like here, you can see that her jowls are much smoother and there's more continuity of the jawline. Here again, this patient wanted an improved facial profile and she really did not want to undergo surgery as she did not have time. She was getting ready to get married in a month, didn't have time to go through a surgical procedure and so opted for a filler. So here you can see how her lower third of her face appears so much more balanced. So she ended up having four syringes of Radiesse to her chin and jawline area. So this is a video of one of the patients I've previously shown where she'd had Radiesse both to her chin and jawline area. You'll see that, I mean, starting with the chin, I marked her off the entire jawline. And then here, this is the blended product of the Radiesse and I'm doing direct injections to her chin and see how I'm molding it. And here I'm actually using, when I start doing the jawline area at the pre-jowl, I actually have a cannula, so I'm also using a cannula. So in her, I'm using a chin and a cannula to inject her chin and jawline. This is another patient, again, we did the combo of the chin and jawline area and already a super beautiful woman, just wanted a more chiseled lower half. Next time, it's gonna follow up with a video of my injecting her. And again, I start off with marking the entire jawline area, the coneal angle. And that's my local before I use a cannula. And I'm injecting where I've drawn, directly underneath, deep sub-Q, directly underneath. And you see my assistant using a little vibration device and it helps kind of slightly distract them. And sometimes you have the patient hold it and helps distraction. And again, we notice what I'm doing with the cannula is that I am only injecting while I'm moving. Same thing with the needle. I only inject on movement, either a forward or backward movement, but always on movement. Recording. And again, this is another patient who's had a chin, jawline filler, but she's also had cabella to a sublentum. So this is a great way where you can address the entire lower half non-surgically. Another patient, again, primarily her chin, and we had done Belafil on her. That's PMMA mixed with bovine collagen. And that is also a great product for injecting the chin area. In this patient, we'd use a slightly different product. This is Voluma. This is an HA filler, again, to give her more balance to her lower face with the chin, lip, and nose. Here again, we had a patient who initially in the past, we had done some Juvederm, and then she wanted a more permanent option, but did not want to have a chin implant. So she's had Belafil. And this is her approximately two years after Belafil treatment, so it lasts a very long time. And again, someone who we had done Belafil on and also did some cabella to reduce the fat in the sub-macular area. Again, you can use the filler in a superficial way. So this is more to improve. You can see the shadowing, the dark shadowing in the chin area. So the filler is now injected very superficially to give more smoothness and brightness to an area when the soft tissue is elevated. So it wasn't necessarily to enhance her chin primarily, but you do see some height increase in her chin. You also see better projection, and you see some brightening of her entire chin area. And again, this is a patient who had a combination, classic V-line face slimming. So she's had the chin filler that we've done in the past. She's also had masseter Botox. And so you'll see how her, these are two different patients, but you'll see how they get nice softening of the jawline, sort of a square jaw. It's more of a narrower jaw and a nice pointier chin like the patient desires. So we also have male patients. So this patient had a full face transformation with just filler. Today, we're going to just concentrate on what we did for his chin and lower face. You'll see the left most picture is his pre-op, the middle is the post-op, and the right picture kind of overdrawn areas that we treated. So in the lower half of the face, we treated the entire jaw. The angle of the jaw going up to the chin area. And this was treated using multiple products. We use something called Volux. It's a very thick G-prime product that is great for the angle of the jaw and the entire jawline. So we use Volux in those areas and then some Velour and Voluma as we came forward to the chin area. So you can literally transform a face within a 30 to 45 minute procedure for him since we also did the upper part of his face. So another gentleman where, again, we started with more of those temporary fillers such as Caja Radiesse. And then since we really liked the results of the temporary filler transition to a permanent filler. So yes, you can mix and match in the sense that you can start with one and then later do another product like Belafil. So now his Belafil has lasted for several years. This is another, again, a typical patient, young male who wants to really have more of a chiseled jawline and a better balanced face. So he has Radiesse filler, both to his jawline and his chin area. And again, things to know, to really keep out of trouble is know your anatomy. And certainly when you start out, it is really safest to use HA fillers because at least there's a product to reverse it using hyaluronidase. I personally like to blend the product so there's less injection pressure. It's really important to clean the area. So when you hear about nodules, et cetera, they're really from very low grade infection or inflammation in that area. So I usually, my cleaning regimen consists of having a wash with soap first and then alcohol and then Hibiclans. I always have a gauze soaked in Hibiclans on the other hand. I like to use ice pretreatment because I think you do get some vasoconstriction, so less chance of bruising and certainly less chance of vascular occlusion. Like I mentioned before, always have hyaluronidase. Signs of trouble. So when you're injecting with some, if the patient suddenly goes, ow, that hurts, you need to stop because that means there is a possibility of it being in a vessel or somewhere in the soft tissue. So, and look for any signs of blanching and this may be just a millisecond. So it's really important to be looking at the area that you're actually injecting. And certainly instructions to give the patient is any worsening pain once they get home, they need to contact you immediately. And again, this may be something that's gonna be in the future is I have an ultrasound and it has helped me to identify arteries prior to injection and this may become standard of care. So certainly something to keep in mind and get trained with for the future. Thank you. And this is a way to reach me. You can contact me, this is my website and my social media pages, but you can also email me directly. Thank you so much, Dr. Rajagopal. Dr. Rajagopal will be joining us as well for the Q&A session at the end, although that was a recorded video. So next I'd like to introduce Dr. Bhaman Gayuron. He's gonna be talking about his geneoplasty algorithm. Dr. Gayuron is a graduate of Turin University Medical School. He completed a residency in general surgery at Boston University in 1978 and a residency in plastic surgery at the Cleveland Clinic Foundation in 1980. Dr. Gayuron also completed a fellowship in cranial facial surgery at Toronto University Hospital for Sick Children in 1980 and he's certified by the American Board of Surgery and the American Board of Plastic Surgery. Dr. Gayuron has served as a director of the section of cranial facial surgery at the Cleveland Clinic Foundation from 1981 to 1983, chief of the division of plastic surgery at the former Mount Sinai Medical Center from 1986 to 1993. And after serving as the division chief for 14 months and chairing the department that he founded for almost eight years at the University Hospital Case Medical Center and Case School of Medicine, he transitioned to private practice in January of 2015 with full continued commitment to residency education and research within the department that he served and developed under the title of emeritus professor. Starting his career with a primary focus in cranial facial surgery, Dr. Gayuron has since applied his principles to aesthetic surgery where he's developed an international reputation for his innovations in rhinoplasty and facial aesthetic surgery. Over the last 23 years, he's captured the attention of the medical and surgical communities with the development of the surgical treatment of migraine headaches with over 44 peer-reviewed publications on this topic alone. Dr. Gayuron has published over 300 articles in peer-reviewed journals, 63 book chapters and six textbooks. He served as editor-in-chief of Aesthetic Plastic Surgery from 2016 to June of 2023. Additionally, Dr. Gayuron has been intimately involved in the education of plastic surgery through his participation in over 1500 presentations at regional, national and international conferences. He's lectured in over 30 countries and has served as a visiting professor in every respected US medical school. He's a member of 10 professional organizations. Dr. Gayuron has served in leadership roles in numerous professional organizations and in plastic surgery, including the American Board of Plastic Surgery, where he served as director from 2005 to 2011. He also served as the president of the American Association of Plastic Surgeons, American Society of Maxillofacial Surgeons, Aesthetic Surgery Education and Research Foundation, the Rhinoplasty Society, Northeast Ohio Society for Plastic and Reconstructive Surgeons and the Ohio Valley Society for Plastic and Reconstructive Surgeons. He's received numerous awards for his accomplishments for every prestigious plastic surgery organization. He also serves on the board of several civic and public organizations, his entrepreneurial activities, including inventions of multiple medical and non-medical devices. Dr. Gayuron, as always, it's such an honor to have you on this panel. And I think all of us always stop when we know you're gonna be there so we can listen to all of your pearls and learn from you. So thank you for being a part of this panel and we all look forward to your talk. Thank you. Greg, can you see my slides? Yes, we can. Wonderful. Thank you for that magnanimous introduction, Greg. And I'm delighted to be sharing some thoughts about the chin surgery with you. These are my disclosures. I will not say anything that would have any commercial connotations. And I don't have a single procedure that probably is appropriate for every patient. And I'm going to share with you variety of techniques that I use. And all of what I'm going to share with you doesn't require having craniofacial training. And it boils down to proper detection of the chin deformity in order to deliver a successful outcome. And I do analyze the entire face because we're going to be matching the chin to the rest of the face. And on somebody who has a class one occlusion like what you see in the illustration, there's no problem. On the other hand, when a patient has a class two or class three abnormalities, delivering an optimal result from the geneoplasty proves difficult. And I do like this Rydell line, which is a line that connects the upper and lower lip most prominent projected portion to the chin. And it should be touching the most prominent portion of the chin. And if we adhere to this principle, we can always get really good results. And I'm going to show you many cases and every single one of them is going to have this alignment. But I also, as Jacques mentioned, we have to be careful about patients who have significant maxillary mandibular deformities. And these are the patients that are not going to benefit from the chin surgery alone. These patients need orthognathic surgery. This patient had a combination with upper and lower joint geneoplasty in order to get the result that you see. And he showed several cases. I'd like to show you this patient who had two previous geneoplasties. And in fact, the Rydell's line is okay. But the problem is that this patient has significant maxillary mandibular flaws. And when I correct that, you can see how everything is lined up properly now. And this goes back a long while ago. And we do see some really complex situations like this, that again, geneoplasty is not an answer for this patient. Although I did a geneoplasty on her also, but as you can see, I reconstructed her TMJ, joint mandibular maxillary osteotomy, and she was able to open the mouth. She was ankylosed and she wasn't open previously. You can see the facial drastic change and change in the profile. But this, again, is a rare situation. So what we need to do is discuss options that we have for the patients who do not have major maxillary mandibular abnormalities. And that includes fat injections, implant, osteotomy, combination of osteotomy and fat injection. And I'll tell you when that becomes a really suitable choice for us. And I introduced the classification of chin deformities, which is really a practical guideline as to detection of the chin abnormalities. And the most common one is obviously microgenia, which can be horizontal, as you can see here, vertical, or combination. These patients are going to require different movement in the chin segment in order to deliver results. If the microgenia is horizontal, there are choices are implant, osteotomy, fat injection. And I use all of these. On an older patient, I used an implant because I don't want to do an osteotomy on. It is done through a submental incision anterior to the existing crease there. We're going to inject the area diffusely with Zylocaine containing one in 100,000 epinephrine, and then make an incision and go down all the way to the bone, elevate the periosteum, and create a pocket, symmetric pocket that is going to accommodate the implant. It's crucial to do this periosteally so it doesn't cause any irregularities or dimpling in the chin area. I irrigate the cavity space. Then I often have to remodel the available implants to suit the patient's need. And I like this articulated implant that one side is placed and advanced in the, again, the precise pocket that I've created, and the other one is placed, and we're going to join these in the midline. You will notice that I have actually marked my midline down here on the incision for alignment of the incision when I repair it and alignment of the implant. So you notice that I'm actually moving the implant a little bit to make sure that it is in the midline. And it is crucial also to observe any asymmetric or existing asymmetries in the chin area and accommodate and adjust the aesthetic plans to make sure that we're not going to transfer that asymmetry to the final outcome. And the repair will include approximation of the deeper layers, the muscle and the periosteum. Then this will be a three-layer closure, and the final layer will be 6-0 plain CAD-CUT. I use fat injection for contouring, for augmentation, or prevention of a deep labial-mental groove. That's unfortunately, it's a nasolabial, labiomental groove. And I use the Coleman technique. I inject two or three cc's in the labiomental groove if it is deep, and this is a very unattractive feature. Whenever we make that, either as an iatrogenic product or originally there's a deep labiomental groove, it is very undesirable. So I inject two cc's, two or three cc's there, four to six cc's for augmentation of the chin, and once, one to two cc's to the lateral chin area that Jacques earlier mentioned that it can be problematic. Here is the injection of fat in the labiomental groove to advance the labiomental groove. And whenever we advance the chin, we need to look in this area to make sure that it is not more than four millimeter deep for a female and six millimeter deep for a male. And injection of the chin proper for augmentation and lateral injection for elimination of any furrowing in that area that Jacques mentioned earlier sometime after the chin advancement, it may come about. And here's the patient who had chin augmentation using fat injection alone. Even you can, in this scenario, I've been able to adjust the chin enough to meet the requirement of the Rydell's line. This is a combination of genioplasty, osteotomy and advancement, and fat injection in this area. You can see, had I advanced the chin alone without advancing the B point, this would have been even deeper and more or less attractive than what we see here. And you can see now everything is lined up properly. And if I need, again, inject fat laterally, I would do it. Here is a patient who has significant flaws to the chin area, congenital. This is not a product of any kind of chin surgery. And here he is after a lip lift and a lip augmentation plus chin fat injection to make the chin more desirable and smoother. And you can see all the other things that were done for the neck area. On a younger patient, I do, with microgenia, I'm going to use an osteotomy, sliding osteotomy, which is extremely versatile because after you free up that segment, you can move it in any direction. And I use one plate only. Here's a technique that I use. I inject the area with Zydeco and contain 100,000 epinephrine diffusely inside, internally, externally. And then we're going to make an incision, leaving at least a centimeter of soft tissue on the gingival side to facilitate proper repair. And then I'm going to take this incision deeper, elevate the periosteum diffusely, and put malleable retractors in position to protect the soft tissues outlining the midline. And we need to make sure that our horizontal osteotomy is below, at least four or five millimeters below the mental foramen, because that nerve goes caudally before it becomes superficial. So I use a power tool to create my outline, my midline. Then we're going to use wider osteotome for the central portion, narrow osteotome laterally, while again, the soft tissues are protected and advance the segment. And also for the significant advancement, I release the anterior belly of digastric muscle. They use a single plate, prefabricated plate, and four screws, and that will be the end. Whenever there is an irrigated wound, then we're going to repair the incision very precisely at approximating full thickness of the incision back to where it was. And you use mattress sutures for this, and several of them to make sure that we don't create lip incompetence. I agree with Jacques that actually this osteotomy has the power to eliminate any kind of lip incompetence. And again, lateral incision, the lateral portion of the incision being repaired. And when we do that, we can create natural looking chin that again, lined up according to the Rydell's line. Lined up according to the Rydell's line. On some patients, I do a combination of genioplasty and rhinoplasty, and this again, enhances the rhinoplasty results tremendously. And if I have any gap in the bone, I'm going to correct it with the bone from the septum. This is a patient who needed elongation. Or when the segment is being advanced significantly, I use some bone there. If the advancement only is more than five millimeters, you need bone graft. Here, as you can see, the combination of osteotomy and also rhinoplasty on a patient who was having significant advancement, you can see I've used a bone graft. This is a case that I did actually in Italy. Enrico Robardi invited me to operate there, and we did a genioplasty and used the bone graft. And another good indication for this type of surgery is on patients with cleft lip, cleft nose deformity. You can see we have created, we have improved that. And the other category of the chin deformity is prominent chin or macrogenia, which can be horizontal, vertical, or combination. It's a patient who has a horizontal prominence, she had a combination of rhinoplasty and reduction genioplasty through submental incision, just shaved on the bone. But this patient needed something different. On her, I actually shortened the chin again. You can see how the Rydell line works there. And a combination of submental lipectomy and genioplasty, it becomes very powerful, and I use it frequently, combination of rhinoplasty, genioplasty, and submental lipectomy can create profiles like this. So it is another patient with similar rhinoplasty, genioplasty, submental lipectomy to transform this face. And I use it again very commonly. So the pearls to take home, number one is to make sure that we leave enough sufficient soft tissues for the repair so it doesn't cause any retraction of the gingiva, placing the osteotomy five millimeters below the foramen, protecting the soft tissues, awareness of asymmetry, prevention of too deep labial-mental group by adding fat, proper choice of the technique to please the patient, and the role of the submental lipectomy cannot underestimate it. Thank you for your attention. Again, Greg, thank you for the invitation. Thank you so much, Boman, for that great presentation, really amazing results from all of our panelists. And we're gonna now open the floor up to some questions. I do have a couple of questions to start with. The Q&A, it seems like Dr. Seboye, you already answered some of the questions there. Before I go on, there's one question in our chat from one of our attendees. Thanks, everyone, for your talks. I have a question for Dr. Gajdaran regarding fat grafting and chin augmentation. What type of fat preparation technique do you use and in which planes do you apply it? Yes, as I mentioned, I use the Coleman technique. I centrifuge the fat and I actually, it depends on the condition that I'm dealing with. On patients who have dimpling irregularities of the chin, I'm going to be very superficial, meaning immediately subcutaneous plane. And sometimes I'm injecting some of the fat in the dermal layer. On patients who have smoother skin, I don't wanna take a chance of creating irregularities. So I'm going to inject it in the muscle and even get close to the periosteum. As I mentioned, I use somewhere between two to four CCs, depending on how much I, have I injected more? Yes, the maximum that I've injected, eight CCs. It has been eight CCs. And Bobby, when you do your sliding genioplasty, just to kind of springboard off of that same question, are you comfortable adding fat in that particular case as well? I am actually. You remember Jacques mentioned something about deficiency, a problem with the osteotomy is that sometimes it creates a little bit of hollowing to the lateral chin area. That is when I use fat there. And then also I use fat in the B point, meaning to reduce the potential for any type of deep labiamental groove. And those two occasions I use, that's why I mentioned actually a combination of osteotomy. And it really takes, because injected fat is going to be within the soft tissues. I'm not really packing the fat between the periosteum and the bone. It is in the subcutaneous tissues. It takes like anywhere else. Yeah, thank you. Jacques, can I ask you a question? So chin wing osteotomies are typically or classically described for people with normal occlusion. So you mentioned that the fact that you do combine this with other osteotomies for patients who have malocclusion. So can you just comment, how often would you say you're performing this on someone with malocclusion versus just normal occlusion, who's just looking for an aesthetic result? And do you do anything differently when you're doing that or are there any precautions you should take? No, it's not different. It's the same technique, but we have two kinds of people. People are coming only for an aesthetic problem as a class one occlusion. And they want only something on the chin because of the aesthetic aspect of the chin. And because sometimes, and they don't know exactly. And I explained to them that they have a level of incompetency and we can change both things. These people are only for aesthetic problems and functional, but they don't know really that they have this problem. The other people are coming with malocclusion. And sometimes when you repair the malocclusion, if you don't take care of the chin, you have a very bad result. You have a very good occlusion, but a bad result. And sometimes you have a level of incompetency. So I think in our program of surgery of the malocclusion and the orthodontic surgery, we have to put inside the chin wing or genioplasty because it's with this technique you have best result on your orthodontic surgery, I think. Thank you. And one more question for you, I'm not a craniofacial surgeon. So I was kind of interested in your gingival approach. So, and moreover, how do you, I saw you suturing, but how do you secure that? And is there a specific postoperative protocol that you need to use specifically for these patients? I tried this 10 years ago and I was a bit, sometimes one of the guys asked, do we have some recessions? And if you do it gentle, one by one, and you go through, direct this to the bone, you have results unbelievable because you have no scar, nothing, no scar. And you, at the end, you suture each one. And then in 10 days, it's normal, nothing, nothing. Because in the past, I do it in the lower part, in the upper part. And sometimes when you suture, sometimes you have a little reduction of the lip or because you can get some muscle or something. Here you have nothing, you put everything out, you put it again down, it's the same. And it's like a suit, you should put it. It's wonderful, wonderful. I will not change anymore, but it's 15 minutes more. Of course. Thank you, thank you for that. I do have a question. Dr. Rajagopal, are you with us? Do you mind turning your camera on? Usha, are you with us tonight? Yes, I am. Great, so I thank you for your presentation. I just would like an explanation just for the audience about, you mentioned that you use blended fillers. Can you just kind of expand upon that, what you mean by blended fillers? Yeah, so when I say blended, what I'm doing is I'm actually mixing the filler with normal saline. So my most common blend is if I'm using one syringe of an AHA product, and that's what I generally use, AHA. So one CC of AHA product with 0.5 CCs of normal saline. And I use a female to female adapter and literally blend it in. And so that means at the end, the blended product is 1.5 CCs. And then that's what I use to inject. And so theoretically and certainly practically, so when you're injecting a filler that is less dense or less viscous, now that you've had saline in it, when you inject it, you actually have to exert much less pressure when you're injecting it. So most vascular occlusion issues happen because of the retrograde propagation of the product going the wrong way up the vessel. That's usually what happens. And then it gets into the N arteries and that's why you get tissue necrosis. So if you can prevent that forceful retrograde propagation of the filler, you're gonna be much safer. So I feel like blending is, that's why I like to blend. Other reasons I would blend is it's easy to mold once you have it in and there's less swelling. But you do need to understand that, I mean, it's a very short learning curve to understand that you do need to deposit more of that blended product in an area to get the same effect. But that you will learn within a couple of patients. Thank you. I think that's really helpful. Can you also just kind of expand slightly upon, yeah, you showed a lot of great jawline filler. Can you just expand upon your planes of fill? Where exactly are you putting filler during that? Depending, I know you're using several products, but where exactly is it being placed? Yes, it really depends on the thickness of viscosity or the G prime of the filler, if I'm using an HA product. So generally, and now there is a product made preferentially for the jawline in the sense that it is very, very thick. So that is the only area you can inject it. So I'm gonna name it, it's called Volux. So it's even thicker than the fillers you would use for the cheek, et cetera, or even the chin. I've had patients who, when I've injected that product in the chin, it doesn't feel right. So anyway, so when I inject that deep, thick product, I inject a quite deep sub-Q. And so I would say it would be deep sub-Q supraperiosteal along the gonial angle going up and the same along the jawline going down. So that product would be injected very deep. And then I will mold as I go along, if I think the border isn't very smooth. And the way I mold it is, just like when you're doing rhinoplasty, you wet your finger when you run around the dorsum, when you're shaving down a hump. Same thing in here, I will wet my finger with a little Hibiclens and run it along any area that I've injected, make sure it's smooth and there's no bump. If I'm doing a product that's maybe not as thick, so next level in thickness would be, then I would go deep sub-Q, but not maybe subperiosteal because I do wanna see an effect obviously through the skin. So if you go very deep with a product, then it's not gonna actually transmit through the skin. So you kind of have to go use a little bit of visual feedback as to the depth of how you're going, but generally relatively deep sub-Q in the jawline products. That's great. Thank you very much. I think that really helps clarify things. So we are at time, we're at eight o'clock, we're at time. I wanna thank everybody for coming. We do have two open questions in the chat, which we will email to both of our panelists and have those answered as well. So if you have questions in the chat right now, don't worry, they will absolutely get answered. So we just apologize. We just wanna keep everybody on time. I wanna thank Dr. Savoy, Dr. Guyeran, Dr. Rajagopal for joining us tonight and thank all of you for taking the time this evening, this afternoon, this morning, depending on where you're watching from for joining. It really was a great panel. This is recorded, you can find it on ASPS on EdNet. So if you missed it or if you wanna recommend it, please go back and look for it. And I hope we're gonna see many of you in San Diego. So we look forward to all of that. Thank you all. Have a great night. And once again, thank you to our panelists, just terrific talks. And thank you for sharing your expertise with us this evening.

chin correction

Gregory Greco

chin wing osteotomy

dermal fillers

facial symmetry

Riedel line

ASPS EdNet

bone grafts

facial anatomy

plastic surgery