CLINICAL ▼
Chin analysis and augmentation:
anatomy, interventions and complications
Abstract
The chin has a profound effect on facial attractiveness and much of the character
of the lower face. Despite this, the chin is normally overlooked when it comes
to aesthetic alterations of the face. It can be altered surgically through osseous
manipulation or implant augmentation to harmonise and re-establish the balance
between skeletal, soft tissues, and dental components of the lower face. Non-
surgical alteration of the chin can be achieved by botulinum toxin injections and
dermal fillers used as implants for enhancement.
Key words
► Chin ► Bone resorption ► Botulinum toxin ► Dermal fillers ► Dentition
T
he chin and its defining characteristics have a
significant impact on the harmony and aesthetic
of the face, especially in profile view (Naini,
2011) (Figure 1). The character of the lower face
largely relies on the chin’s shape, contour and position
(Naini, 2011), and its prominence can be a key factor in
the perception of facial attractiveness (Naini et al, 2012).
A deficient chin may lead to the lower face merging with
the neck, which is not aesthetically pleasing.
In addition to its role in facial aesthetics, the chin
is one of the facial characteristics that people often
associate with an individual’s personality (Naini, 2011). It
is not uncommon to hear people remark that someone
has a ‘weak’ or a ‘strong’ chin. Some authors have even
suggested that a prominent chin in men may be seen as
strength of personality (Naini, 2011).
In this article, the author will describe relevant lower
facial anatomy landmarks, advise aesthetic practitioners
in the analysis of the chin, and recommend evidence-
based treatment options for chin augmentation.
Chin augmentation
Having a significantly prominent or retrusive (backward
displacement) chin is a common reason for patients
seeking treatment, from surgical procedures, such as
SOUPHIYEH SAMIZADEH
Dental Surgeon and Clinical Director, Revivify London.
e: info@revivify.london
8
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orthognathic surgery and/or genioplasty (the surgical
approach to alter the chin through either osseous
manipulation or implant augmentation) (Naini et al,
2012), to non-surgical interventions, such as cosmetic
injectables. It is important to note that, although the chin
can be non-surgically modified using botulinum toxin
and dermal fillers, reduction of the chin height or width
cannot be achieved non-surgically. Surgical procedures
such as osseous manipulation may be required.
Lower facial anatomy
A comprehensive understanding of the anatomy of
the chin and its surrounding areas is crucial before
commencing treatment. The lower lip, mentolabial fold
and chin’s aesthetics and anatomy are closely related.
The chin has a bony projection of the mandible, the
mandibular symphyseal region, which is covered by
the soft tissue overlying the chin (the chin pad) (Naini,
2011; Lee, 2013). The chin is defined by the labiomental
crease superiorly, the oral commissures laterally, and
the submental-cervical crease inferiorly (Lee, 2013).
The layers of the chin are the skin, superficial fat
compartment, mentalis muscle, deep fat compartment
and bone (Braz et al, 2015).
The root apices of the lower anterior teeth are superior
to this region of the mandible (Figure 2), and the mental
foramen can be found around the apices of the lower
second premolar teeth (Oliveira Junior et al, 2009)—take
caution when injecting deep in this region.
The bony chin affects the position of the soft tissues,
and dysmorphology of the chin results in distortion of
the labiomental fold (Lee, 2013). A deep labiomental
fold is usually observed in those with reduced lower
vertical face height and a retrusive chin (Lee, 2013).
Conversely, a flat labiomental fold is seen in people with
increased vertical lower face height and a horizontally
deficient chin (Lee, 2013). These individuals also suffer
from difficulty in lip closure and mentalis muscle strain
(Lee, 2013).
© 2016 MA Healthcare Ltd
Musculature
Regional musculature (Prendergast, 2013) includes the:
►► Mentalis
►► Quadratis labii inferioris
►► Triangularis
►► Superior portions of the platysma.
Journal of AESTHETIC NURSING ► February 2016 ► Volume 5 Issue 1
 CLINICAL ▼
Andrew Bezear
1 carried out in sagittal (anterior to posterior), vertical and
2 the following areas (Lee, 2013):
3 ►► The soft tissue envelope, i.e. the chin pad.
A The patient’s chin should be evaluated in the following
Figure 1. Facial profile image with facial thirds: 1, trichion to glabella;
2, glabella to subnasale; 3, subnasale to menton. A: mentolabial depth
Andrew Bezear
Mental foramen
Apices of lower incisors
Mental protuberance
Figure 2. The size and shape of the bones making up the mental
protuberance are responsible for the size and shape of the chin
Nerve distribution
The mental nerve supplies the cutaneous chin, the lower
lip, and the inner vestibule (Siemionow and Sonmez,
2008). The motor innervation of the muscles is derived
from the facial nerve, the marginal mandibular and
cervical branches (Siemionow and Sonmez, 2008).
10
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Clinical evaluation and analysis
Systematic analysis of the facial features and the chin is
critical for making a correct diagnosis and developing
an accurate, effective treatment plan. Analysis should be
transverse (horizontal) planes (Naini, 2011). It is advisable
to analyse the face during animation as well in a static
position (Naini, 2011; Lee, 2013). Analysis should cover
►► The lower face and its relationship to whole face
►► The dental relationship
►► The maxilla-mandibular skeletal morphology
positions (Naini, 2011):
►► Natural head position: it is important to take into
consideration that it is not uncommon for people to
develop a compensatory head position to minimise
the aesthetic impact of their facial appearance
►► Mandibular rest position: the mandible should be
relaxed, and not postured or over-closed
►► Soft tissues relaxed: the lips should be relaxed to avoid
lip strain and get a lip seal.
Symmetry of the chin also needs to be assessed, as the
chin may be asymmetric or out of the normal range in
more than one dimension.
Skeletal evaluation
When undertaking a skeletal evaluation, the following
components need to be assessed (Naini, 2011):
►► Sagittal position of the mandible
►► Size of the mandible
►► Size and sagittal projection of the bony chin
►► Anterior or posterior growth rotation of the mandible.
Soft tissue analysis
Evaluation of the thickness of the soft tissue chin
pad can be undertaken using different methods and
in relation to different facial planes. To simplify such
analysis, this article will discuss evaluation using
the true vertical plane through the soft tissue nasion
or glabella. However, it is important for aesthetic
practitioners to keep in mind that the position and
prominence of nasion may vary for each patient.
With the patient in the natural head position, the
following lines need to be drawn (Figure 3):
►► The true horizontal plane
►► A perpendicular line from the nasion/glabella to a
true horizontal plane, i.e. the true vertical plane.
The aesthetic soft tissue pogonion—the most
© 2016 MA Healthcare Ltd
forward-projecting point on the anterior surface of the
chin)—would be 0+-2 mm from the true vertical plane
(Naini, 2011).
If the patient’s lips are used as points of reference
(e.g. the Riedel analysis), it is important to ensure the
sagittal lip positions are correct (Naini, 2011).
Journal of AESTHETIC NURSING ► February 2016 ► Volume 5 Issue 1
 ▼ CLINICAL

Treatment planning

Andrew Bezear
Gender
In men, the soft tissue over the chin is significantly thicker
than in women (Guyuron, 2008). Morphologically, men
usually have wider, square faces and often have more
projected chins. Female chins are smaller in comparison
and are more round (Naini, 2011; Lee, 2013).

Age
As the projection of the chin changes with age, treatment
of young adults under the age of 18 years is not advisable.
Loss of volume and fat redistribution in the lower third
of the face (chin and mandibular areas) lead to sagging of
the neck, marionette lines, pre-mental hollows, pre-jowl
sulcus, an orange peel appearance, and ptosis of the chin
pad (Hamilton, 2009; Carruthers and Carruthers, 2012).
With ageing, there is also a loss of lateral and inferior
volume of the chin, which results in relative protrusion
of the central chin. Hollowing of the lateral parts (lateral
mental atrophy) results in ptosis (Coleman, 2004; Figure 3. With the patient in the natural head position, true
Coleman and Grover, 2006). In addition, mandibular bone horizontal and vertical lines are drawn to assess the chin’s position
resorption due to ageing and/or loss of dentition, results
in chin pad ptosis (Coleman and Grover, 2006). groups by variations in the orbital region and nose height
and width. In addition, aesthetic ideals vary in different
Ethnicity regions and cultures (e.g. a square face is considered to
Facial morphology varies in different races. For example, be unattractive in the East Asian population) (Khadka et
Farkas et al (2005) distinguished various races or ethnic al, 2011).

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Volume 5 Issue 1 ► February 2016 ► Journal of AESTHETIC NURSING 11

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 CLINICAL ▼
Creative Commons/Caitlin Regan
An irregular contour of the chin could be due to the loss or absence of bone or soft tissue support
Treatment options and outcomes
As excess cannot be treated non-surgically; referral is
required for surgical intervention (Naini, 2011). However,
chin and mandibular deficiency can be improved using
non-surgical interventions, such as the injection of
dermal fillers (Braz et al, 2015). For these patients, dermal
fillers act as an implant, enhancing the projection of the
chin’s length and the face (Braz et al, 2015).
The mentalis originates from the bone (incisive fossa
of the mandible) and inserts into the dermis of the chin.
Contraction of the mentalis muscles results in elevation
of the medial part of the lower lip, protrusion of the
lower lip, and creates the orange peel-like dimpling of
the skin over the chin (Le Louarn, 2001; Prendergast,
2012a). Constant mentalis muscle contraction can result
in a flat chin (Le Louarn, 2001).
Evaluation of the occlusion, skeletal and dental
relationships must be performed before considering
a patient for chin augmentation (de Maio and Rzany,
2006). To manage expectations, it is important to inform
patients that the results with biodegradable fillers are
temporary and long-term results will not be achieved.
Dermal fillers
An irregular contour of the chin could be due to the loss
or absence of bone or soft tissue support (de Maio and
Rzany, 2006). To enhance the chin, fillers can be used.
The best candidates for fillers are people with normal
occlusion, and those who have a good chin projection
with little or no lateral fullness (de Maio and Rzany, 2006).
Depot injections can be placed on the anterior or
inferior aspect of the menton, on the periosteum,
12
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depending on aesthetic goals (Prendergast, 2012b). For
those individuals who require forward and downward
projection, enhancing the upper and lower part of the
menton with dermal fillers will achieve the goal and
balance the face (de Maio and Rzany, 2006). If injecting
in the pre-jowl sulcus, fillers can be placed in the
subdermal plane to avoid the facial artery and vein that
are pre-periosteal (Carruthers et al, 2005).
Botulinum toxin
Botulinum toxin temporarily causes muscle paralysis
through inhibition of acetylcholine release at peripheral
cholinergic nerve terminals (Bitar et al, 2012). Le Louarn
(2001) reported that superficial medial injections of
botulinum toxin type A in the upper part of the muscle
would maintain the lower part contraction, hence
creating a chin advancement with softening of the skin
of the upper part of the mentalis area (Le Louarn, 2001).
Chemodenervation of mentalis muscle softens the
dermal insertions of the muscle (Prendergast, 2012a).
In addition, mentalis muscle hyperactivity results in
the formation of an irregular chin contour. This can be
treated by injecting botulinum toxin A in both men and
women at 1–2 injection points (Bitar et al, 2012).
Complications and management
© 2016 MA Healthcare Ltd
Complications can be prevented by employing accurate
injection techniques and choosing the correct product.
Inaccurate injections will at best lead to suboptimal
results and complications. To avoid complications
and spread of botulinum toxin to unwanted muscles,
conservative doses should be used and the injections
Journal of AESTHETIC NURSING ► February 2016 ► Volume 5 Issue 1

should be accurately placed to selectively denervate
muscles (Prendergast, 2012a). Knowledge of the depth
of vasculature and nerve distribution of the chin and its
surrounding structures is essential. It is also important
to note the patient’s history of previous treatments in the
same facial area and treat these patients with caution.
Minor complications
Minor complications of dermal fillers include pain,
oedema and erythema, which are transient and typically
self-limiting (Buckingham et al, 2010; Dayan et al,
2014). Too superficial injections will result in unwanted
lumps or palpable beads, and this may persist for several
months (Buckingham et al, 2010; Dayan et al, 2014).
Infection at the injection sites can also be mistaken for
allergic reactions. Low-grade bacterial infection may
play a role in delayed-onset adverse reactions and these
patients should be treated with antibiotics (Buckingham
et al, 2010; Dayan et al, 2014).
The longevity of dermal fillers is also a significant factor.
Although hyaluronic acid dermal fillers are thought to
have temporary effects, some fillers, have been reported
to persist as long as 5 years post-injection (Buckingham
et al, 2010; Dayan et al, 2014). In susceptible patients,
reactivation of herpetic eruptions followed by localised
bacterial infection may occur (Dayan et al, 2014).
0120
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© 2016 MA Healthcare Ltd
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Volume 5 Issue 1 ► February 2016 ► Journal of AESTHETIC NURSING
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▼ CLINICAL
Key points
►► The chin plays a significant role in overall facial
attractiveness and the character of the lower face
►► The skeletal, soft tissues and dental components need
to be understood and evaluated
►► Gender, age and ethnicity are important factors to
consider when treating the chin
►► The chin should be evaluated with the patient in
natural head position, mandibular rest position, and
when soft tissues are relaxed
►► Vertical or horizontal excess cannot be treated non-
surgically and requires surgical intervention
Major complications
One of the major complications of dermal fillers is
necrosis, which occurs due to compromised blood
supply. As reported by Dayan et al (2014), manifestations
of impending skin necrosis, such as immediate or early
skin blanching, dusky or purple colour of the skin, or
violaceous changes of the skin in a reticular pattern,
must be treated as such, unless proven otherwise.
Very rare but catastrophically, embolic events can
result in irreversible loss of vision or cerebrovascular
Distributed in the UK by
SoftFil® Masks SoftFil® Skin Rollers
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13
 CLINICAL ▼

injury (Dayan et al, 2014). To minimise risk of adverse
effects, the following measures should be taken (Dayan
et al, 2014):
►► Aspiration before injection
►► The volume of dermal filler injection should be limited
to <0.01ml per pass
►► Slow pace of injection
►► Low pressure of injection
►► Use of blunt cannulas where possible.
Conclusion
The chin is an anatomical area defined by the
labiomental crease, the oral commissures and the
submental-cervical crease. It is often disregarded when
it comes to the aesthetic modification of the face;
however, it plays an important role in overall facial
attractiveness and the character of the lower face. The
size, shape, and contour of the chin is significant for
a well-balanced and harmonious face. Modification of
the chin requires understanding of the anatomy, and
the balance between skeletal, soft tissues, and dental
components of the lower face. Non-surgical alterations
include chin enhancement using dermal fillers. Severe
skeletal deficiencies/deformities and excess may require
surgical intervention. 
References
Bitar GJ, Choi DJ, Segura F (2012) Botulinum toxin for facial
rejuvenation. In: Erian A, Shiffman MA, eds. Advanced Surgical
Facial Rejuvenation. Springer, Berlin
Braz A, Humphrey S, Weinkle S et al (2015) Lower face:
clinical anatomy and regional approaches with injectable
fillers. Plast Reconstr Surg 136(5S): 235S–57S. doi: 10.1097/
PRS.0000000000001836
Buckingham ED, Bader B, Smith SP (2010) Autologous fat and
fillers in periocular rejuvenation. Facial Plast Surg Clin North Am
18(3): 385–98 doi: 10.1016/j.fsc.2010.04.003
Carruthers A, Carruthers J, Dover JS (2005) Soft Tissue
Augmentation: Procedures in Cosmetic Dermatology Series.
Saunders, Philadelphia PA
Carruthers J, Carruthers A (2012) Soft Tissue Augmentation:
Procedures in Cosmetic Dermatology Series. 3rd edn. Saunders,
Philadelphia PA
Coleman S (2004) Structural Fat Grafting. Quality Medical
Publishing, St Louis MO
Coleman SR, Grover R (2006) The anatomy of the aging face:
volume loss and changes in 3-dimensional topography. Aesthet
Surg J 26(1S): S4–9. doi: 10.1016/j.asj.2005.09.012
Dayan SH, Brennan TE, Arkins JP (2014) Filler augmentation. In:
Myint SA, ed. Nonsurgical Peri-orbital Rejuvenation. Springer,
New York Publishing NY
de Maio M, Rzany B (2006) Injectable Fillers in Aesthetic Medicine.
Springer, Berlin
Farkas LG, Katic MJ, Forrest CR (2005) International
anthropometric study of facial morphology in various ethnic
groups/races. J Craniofac Surg 16(4): 615–46
Guyuron B (2008) MOC-PS(SM) CME article: genioplasty.
Plast Reconstr Surg 121(4 Suppl): 1–7. doi: 10.1097/01.
prs.0000305931.98111.c3
Hamilton TK (2009) Skin augmentation and correction: the new
generation of dermal fillers—a dermatologist’s experience. Clin
Dermatol 27(3): S13–S22. doi: 10.1016/j.clindermatol.2008.12.001
Khadka A, Hsu Y, Hu J et al (2011) Clinical observations of
correction of square jaw in East Asian individuals. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 111(4): 428–34. doi: 10.1016/j.
tripleo.2010.05.061
Lee EI (2013) Aesthetic alteration of the chin. Semin Plast Surg 27(3):
155–60. doi: 10.1055/s-0033-1357113
Le Louarn C (2001) Botulinum toxin A and facial lines: the variable
concentration. Aest Plast Surg 25(2): 73–84
Naini FB (2011) Facial Aesthetics: Concepts and Clinical Diagnosis. 1st
edn. Wiley-Blackwell, Oxford
Naini FB, Donaldson AN, McDonald F, Cobourne MT (2012)
Assessing the influence of chin prominence on perceived
attractiveness in the orthognathic patient, clinician and
layperson. Int J Oral Maxillofac Surg 41(7): 839–46. doi: 10.1016/j.
ijom.2012.01.012
Oliveira Junior E, Araújo A, Da Silva C et al (2009) Morphological
and morphometric study of the mental foramen on the M-CP-18
Jiachenjiang point. Int J Morphol 27(1): 231–8
Prendergast PM (2012a) Botulinum toxins. In: Prendergast PM,
Shiffman MA, eds. Aesthetic Medicine: Art and Techniques.
Springer, Berlin
Prendergast PM (2012b) Augmentation with injectable fillers. In:
Prendergast PM, Shiffman MA, eds. Aesthetic Medicine: Art and
Techniques. Springer, Berlin
Prendergast PM (2013) Anatomy of the face and neck. Cosmetic
Surgery: Art and Techniques. Springer, Berlin
Siemionow M, Sonmez E (2008) Face as an organ. Ann Plast Surg
61(3): 345–52. doi: 10.1097/SAP.0b013e3181844ea3

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