Q: Dr. Eppley, I was interested in removing the dimple or cleft in my chin. I have attached pictures of it so you can see if chin cleft removal will work for me. It is not a big chin cleft but it bothers me nonetheless.
A: Thank you for sending your pictures. What you have is a lower vertical chin cleft which is a direct manifestation of a notch in the chin bone. If you feel the chin bone under the cleft you will probably feel a notch or a groove in the middle of the chin bone. In this type of cleft it is important to fill in the bone ‘defect’ as well as add a little fat right into the soft tissue portion of the chin cleft since it also is making a contribution. This is done from inside the mouth with the placement of a very small mesh implant into the bony groove. The fat can be harvested from inside the bely button and injected into the soft tissue cleft or a small graft can be harvested from inside the mouth from the buccal fat pad and placed directly into the defect.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in chin cleft removal surgery. The deepest part of my cleft is at the very top. Ironically, the deepest part at the top goes down to the bone, which is not a valley but a peak at this part of the cleft. So the top is strictly due to the positioning of the attached muscle. The bone is grooved at the bottom of the chin with a 1/8th inch deep notch in the bone. This is basically the deepest possible cleft chin possible.
From what I’ve read, entering through the mouth to avoid scarring this is the best that can be done and will most likely not fully remove the cleft but dampen it. I would like to know how many cleft chin removals using subcutaneous fat as a filler with smoothing of the chin bone have you done?
A: When it comes to chin cleft removal (or more accurately for many patients a chin cleft reduction), it is important to classify the type/depth of chin cleft. I classify chin clefts into four types based on the clefting seen in the skin, fat, muscle and bone levels. By your description and the example you have shown which corollates to your chin cleft, that would be a type IV chin cleft. When the chin cleft is this deep and the skin edges are deeply inverted, placing a filler material in the cleft is really not the best treatment. The tissues are so deeply indented that it will resist any ‘soft’ push from any underlying augmentation in the soft tissue layer. Augmentation of the bone, although reasonable to do, has the less effect on Type III and IV chin clefts. The most effective treatment in Type IV chin clefts is external excision and multiple layer reapproximation to level out the clefted tissues all the way down to bone. While this is the best approach in very deep chin clefts, this creates an external scar which is rarely aesthetically acceptable. Thus one has to accept an internal intraoral approach with a much reduced result. If done intraorally, the bony cleft would be augmented, the skin released from the muscle and a dermal-fat graft placed underneath the released skin. I would expect maybe a 1/3 to 1/2 reduction in the Type IV chin cleft with this approach.
One simple test to determine how much a chin cleft can be reduced, a saline or synthetic injectable filler treatment can be done in the office. If reasonably successful that would indicate that soft tissue filling would be reasonable to do. One could then proceed with either fat injections or a longer lasting more robust filler like Juvederm Voluma for treatment. If unsuccessful, then one knows that a more invasive procedure as I have described above would be needed.
Dr. Barry Eppley
Q: Dr. Eppley, I have a very deep cleft on my chin. A surgeon suggested dermal filler, saying that a chin implant would move because (he said) the dimple was too small. But my cleft chin is very deep and I am very unhappy with it. A doctor injected a syringe of hyaluronic acid into last year but with no visible improvement. I have placed a link to an image of my chin cleft here.
A: Very deep chin clefts in men are not usually the result of any underlying bone deficiency but are rooted in the soft tissue with a lack of tissue between the skin and the underlying muscle. Often the mentalis muscle is clefted as well. In addition the skin is very indented almost like a scar band. Thus a chin implant on the bone is likely to be of little benefit as pushing out from the bone will make little change in the depth of the cleft. Injectable fillers, as has been demonstrated by your experience, do not have enough stiffness and volumetric push to change the cleft. The viable treatment options would be either fat injections done with a subcision release of the vertical skin indentation or an open approach using a dermal-fat graft. In some cases the placement of a small implant in a midline bony groove can be of adjunctive benefit if it exists.
When it comes to chin cleft surgery, it is best to think of it as a reduction rather than a complete removal.
Dr. Barry Eppley
Q: Dr. Eppley, I have come across your website as you seem to be one of the few surgeons who offer chin cleft removal/reduction without the aid of implants or fillers. I am strongly interested in the procedure and I would like to know how it is done and understand how long the recovery time is. I would be willing to travel to undergo this surgery.
A: Chin cleft removal can be done without the use of implants or injectable fillers by treating the underlying muscle separation by muscle repair and a buccal fat graft. While an injectable filler is simpler, the lack of a permanent injectable material (short of fat) makes this a temporary fix. This is not to say that using a particulated filler (like Artecoll or Aquamid) with a series of treatments may not be a permanent solution.
This is done as an outpatient procedure under IV sedation. Expect chin swelling for a few weeks afterwards.
Dr. Barry Eppley
Q: Dr. Eppley, I have quite a big cleft/dimple in my chin and I 100% want to get rid of it. I just wanted to know how much this procedure will cost and is it straight forward. Any advice would be hugely appreciated. Thanks
A: Chin dimples and chin clefts have anatomical differnces but they both pose the same problem, getting rid of them 100% is not easily achieved particularly when they are ‘big’. The simplest and most straightforward method is by fat injections. A temporary elimination can be done by synthetic fillers. Fat injections offer the most straightforward approach for not overly deep chin dimples and clefts and are part of the treatment strategy when chin dimples and clefts are very deep. I would need to see some pictures of your chin to determine what is the best approach.
A chin cleft is an actual separation (defect) of the mentalis muscle with subcutaneous fat deficiency. In some cases they may even be a cleft in the underlying chin bone. A chin dimple is an isolated subcutaneous fat deficiency in the chin pad with only minor or negligible muscle deficiency.
Dr. Barry Eppley
Q: I have a noticeable cleft in my chin and I was wondering what procedures can be done to remove the cleft and how invasive are they?
A: Soft tissue indentations of the chin can appear as either clefts or dimples. While both involve the chin soft tissues, they are anatomically different. Chin dimples are round depressions in the middle portion of the soft tissue pad of the chin and occur because of a central muscular and fat deficiency. There is no underlying bony abnormality. Chin clefts are vertical indentations that run from the middle part of the soft tissue pad down to the lower border of the chin. While they also have a muscle and fat deficiency (cleft of the soft tissues), they almost always have some notching of the lower border of the chin bone as well. (symphysis) Embryologically, it is easy to understand how a chin cleft occurs because of the union of the mandibular arches in the midline during development. It is harder to understand the origin of the central dimple although this likely represents an area of lack of epidermal cell adhesion during the final phase of merging.
Chin cleft surgery is best thought of as a reduction rather than a complete removal. There are two fundamental ways to perform the procedure based on the depth of the cleft and the tolerance for any outward scarring. An intraoral approach can be done where the the tissues under the skin are released from the bone, the cleft of the chin bone is filled in (if deep enough) and the muscles put back together to create more of an outward pout of the muscle. This works well for modest to moderate deep chin clefts. In very deeply grooved chin clefts, this will only provide partial depth reduction. Outward skin excision is more effective in these deeply grooved clefts but the creation of a vertical scar, even if the surrounding skin edges are smooth, may not be cosmetically acceptable.
Dr. Barry Eppley