A case report of using the biodegradable fixation device (Endotine) for double chin with ortho-gnathic surgery

Authors : Dong-Ju Choi, Se-Heung Choi, Byeong-Gi Park, Sang-Sik Chae, Tae-Sun Lee, Jun-Woo Park

Abstract

Orthognathic surgery has been accepted by professions as a useful method to obtain remarkable result in oral and maxillofacial deformities. Now, in development of this method with additional aesthetic surgery, above of them, the soft tissue lifting with absorbable Endotine device is considered as a very excellent method. We reported the case which showed a good result to improve double chin with two jaw surgery and Endotine esthetic surgery simultaneously.

I. Introduction

Recently, Orthognathic surgery has developed technically with a lot of attention and played a leading role in solving dentofacial anomalies. But, for the purpose of improving aesthetic as well as functional aspects, the patient treated with orthognathic surgery has some complaints about lack of the amount of improvement in nasal and neck area after surgery. It is possible to solve in skeletal problems during surgery, while still unpredictable in soft tissue asymmetry after surgery¹. In order to improve these soft tissue asymmetry, the orthognathic surgery need more additional aesthetic surgeries like - chin surgery (chin augmentation, chin reduction), rhinoplasty, facial contouring surgery, and submadibular soft tissue surgery.

Above all, especially loose condition below the chin, in other words – Double chin, is generated by locally accumulation of fat through stretching of thin muscle in the neck area. This is the main factor causing the patient's dissatisfaction, but the suitable surgery is not developed still now. In case of excessive soft tissue below the chin area, local resection or liposuction are widely used for treatment. But, it is impossible to remove all fat tissue completely and if the body weight is increased, the new fat is likely to be concentrated in the region of liposuction area by accumulation of additional fat in residual original fat tissue.²

Traditionally, the 2-stage surgery which means soft tissue repositioning surgery after maxillofacial surgery is preferred, because the change of hard and soft tissue after facial asymmetry surgery has been known as no significant relevance in vertical change and this surgery is more predictable.³ The prognosis of 2-stage surgery is more predictable, but duration of treatment is so long and the patient’s discomfort is increased by more surgical procedures. In recent years, several methods to improve soft tissue incongruity with orthogranthic surgery have been introduced to decrease the patient’s discomfort. Among these many methods, ENDOTINE Ribbon(Coapt System Inc., United state) has been proven its reliability and ease, so it is widely used in forehead or mid-face lifting.^4,5,6 However, it is not yet widely used to treat double chin and a few discussion about this method applicated to orthognathic surgery has been performed.

In this case, the reflected prominent double chin was treated with using a two-jaw surgery and Endotine Ribbon for double chin lifting at the same time. The operation procedure was simple and the result was so effective. So we report this case, becasue aesthetic improvement is good and excellent and patient’s satisfaction is also high.

II. Case report

1. Patient information
A 29-year-old female patient visited the Department of Oral and Maxillofacial Surgery, Kangdong Sacred Heart hospital, Hallym University complaining of asymmetry and malocclusion for orthognathic surgery in November 2012. The patient was referred our clinic after orthodontic treatment in private dental clinic for orthognathic surgery. She was single and had high expectation for aesthetic part and she wanted to improve mid-face depression, long face, double chin and malocclusion.

2. Clinical and radiological examination
As the result of clinical examination, difference of the canting of maxillary posterior area was not big with just 1mm, and asymmetry of the maxilla was not severe. Nasolabial angoe was more than 90 degrees and mild depression was shown in mid-face area. Maxillary anterior teeth was exposed about 5mm in relaxed state, and freeway space was about 4mm. Nose tip was slightly bent to right side, and both upper and lower lip and chin point was shifted to left side about 2mm. Upper and lower central incisors were shifted to left side about 1mm from midline. The occlusion relationship was shown as class I tendency. (fig 1)

Fig 1. Preoperative extraoral and intraoral photographs

In radiographs, the maxillar was mild retrognathism and vertically long tendency compared to whole facial aspect. The mandible was shown as a little protrusion and the both angle were more developed. Chin area was longer than the average. Overall, the mandible was shown asymmetry to be shifted left side. (fig 2)

Fig.2 Preoperative radiographs

The treatment purpose of this patient was improvement of openbite by malocclusion in functional aspect and long face in aesthetic aspect. These problems were planned to treat by Le Fort I osteotomy of the maxilla and mandible BSSRO, angle reduction, and genioplasty. But it was expected to be more severe her double chin after orthognathic surgery, so chin lifting with Endotine Ribbon

3. Orthognathic surgery with chin lifting
In January 2013, under general anesthesia Le Fort I osteotomy of the maxilla and mandible BSSRO , angle reduction, and genioplasty was performed. The maxilla was to upward movement about 3mm in anterior and 4mm in posterior. Additionally, the Medpor augmentation was performed in both depressed paranasal area. The genial area was to backward movement about 2mm and upward about 4mm, so lower part of face was more shorted than before surgery. Also the angle reduction was performed.

After orthognathic surgery, the incision was performed in behind of the both ears by rhytidectomy approach and the soft tissue of double chin area was lifted by Endotine Ribbon. The operation time took an additional 30 minutes and the patient did not appeal any special discomfort with lifted chin area. The precautions of not to greatly extend the neck and excessively shake her head were kept in mind and she was shown to relatively rapid recovery. Immediately after surgery, the effect of lifting did not be recognized prominent and she had concern about being touched Endotine Ribbon device under the skin. But, it was not care much more because it was absorbable material. 4 days after surgery, the stitch out was done and wound was very aesthetically excellent result because the incision line was back in the ear.

Fig 3. Endotine Ribbon and intra-operation photographs

4. 2 weeks after surgery
The swelling on op site was reduced after surgery. Further improved facial aspect and decreased double chin after applying Endotine Ribbon were shown after surgery.

Fig 4. 2 weeks after surgery

5. 6 weeks after surgery
The patient’s facial swelling on op site was nearly subsided and facial expressions were also natural. The side effect such as loosing of fixed endotine Ribbon was not appeared and the patient was very satisfacted in solving all problems on her face at the same time.

Fig 5. 6 weeks after surgery

III. Discussion

The various methods are used to solve disharmony of facial soft tissue. Many procedures like liposuction surgery, botulinum toxin injection, and facial lifting with absorbable material are perfomed for this problem, but above all, the facial lifting with absorbable Endotine are more used to advantage in more simple and predictable result.^7,8
Endotine device is anatomically fixed to the structure site called SMAS - Superficial Muscular Aponeurotic System. In 1976, Mitz V. defined at first the SMAS layer as structure divided into between superficial and deep adipose tissue in parotid and cheek region.⁹ After the study, the phenomenon of sagging the facial skin is just for skin and SMAS structure connected with skin is known as important structure with sagging. SMAS has been recognized as an essential structure in facial lifting. It is located under the skin of the face as a single layer structure composed of a continuous, constant and close to spread over the entire face. SMAS and skin are connected with strong fiber septum(fibrous septa) and moved together when the muscle acts. Therefore, the skin and SMAS should be pull0ed strongly upward and fixed with periosteum or deep tissues, so it can be maintained for a long time and not recurred.

In 2007, Ryan N. researched about Endotine midface st 4.5 device for 121 patients in mid-face lifting and it was known as simple, effective, and easy to learn technique. Among them, 78 patients were treated with rhytidectomy or blepharoplasty and it was revealed to more prominent result.¹⁰ In addition, Anthony P in 2007 reported many cases of eyelid cosmetic rhinoplasty with mid-face lifting using endotine fixation.¹¹ In 2007, Allison M. reported adventages of Endotine about no require a metal screw, no need for suture, and no remove the device after healing. However, possible complications are expected about exposure of device, need for repositioning by asymmetry after surgery, or tenderness of device under the very thin skin. Additional expensive costs are also considered.¹² On the other hand, concerns about side effects are going to be bigger, while a lot of interest is with facial lifting. In 2006, Jennifer L reported some side effects like alopecia on brow fixation, loss of elevation, implant palpability, and paresthesia. And he measured the thickness of the 14 skulls for more safe facial lifting procedure.¹³ In orthognathic surgery area, Choi JY etc in 2010 reported that the procedure of Endotine Ribbon with orthognathic surgery in 10 patients were shown good results about solving lip cant or disharmony of gonial angle area.¹⁴

In this case, the chin lifting was applied to the patient who was expected more severe double chin symphtom after orthognathic surgery and the result is so successful. In general, the tongue and hyoid bone is more downward to keep the airway physiologically when the mandible moves to backward.¹⁵ This makes more obtuse angle of between neck and chin. So, movement of the mandible to backward makes the form of chin and neck anesthetic in double chin patients. In this respect, more good results can be obtained in well-selected patients in procedure with orthognathic surgery.

The patient should be felt some discomfort because the excessive extension and rotation of neck were avoided to fixed entotine device with periosteum and skin layer. Also, the tenderness of device under the thin skin seems inevitable shortcoming. The manufacture describes the device would be absorbed completely in 12 months through hydrolysis. So its safety is somewhat verified. But the more studies are needed about fixation periods by loss of strength of the material itself, integrity and force to downward because of its complete absorbable characteristics.

IV. Conclusion

To date, the facial lifting technique was reported successful for solving the soft tissue disharmony in maxillofacial region. But it is not yet being so many operations with orthognathic surgery at the same time which is shown most noticeable improvement. This is thought to be result of factors that uncertain prognosis and longer operation time are contemplated when the hard and soft tissue surgery are done at the same time. However, if more certain anticipated indication was taken through accurate diagnosis and analysis of facial soft tissue, the Endotine Ribbon procedure with orthognathic surgery would be a great effective method.

VI. Reference

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