Q: Dr. Eppley,I am seeking a facial profile enhancement. I am not happy with the way my profile looks. I would like your recommendation. I have a deviated septum so a rhinoplasty at the same time might be possible? I also have an overbite and I was wondering what you would recommend for receding chin… orthodontics or cosmetic surgery.
A: It is very common to do a septoplasty and rhinoplasty at the same time, known as a septorhinoplasty. You do have a short chin and treating its deficiency combined with neck liposuction would provide the best result. With an existing overbite the question is how significant it is and whether you are prepared for the commitment of a combined orthodontic-jaw advancement surgery treatment program. (orthognathic surgery) If not then a chin implant or sliding genioplasty would be the cosmetic treatment options. A rhinoplasty, chin augmentation and neck liposuction could all be done at the same time for a significant facial profile change. (facial profile enhancement)
A combination of nose, chin and neck changes can make for the most powerful and significant change in one’s facial profile that is possible. It usually takes at least two changes in one’;s face to create the optimal facial profile enhancement.
Q: Dr. Eppley, I originally sought rhinoplasty due to great discomfort concerning the projection of my nose. The tip feels enlarged and out of proportion to the rest of my face as well as deviating to one side. However, after speaking with a surgeon, I have come to learn that my jaw is retrusive which makes my nose look larger. I would like to know whether or not you think I would benefit from both jaw and rhinoplasty surgery, or whether you think one or the other would be enough to balance my face. I have attached some photographs in this email.
A: Thank you for sending your pictures. I think it is quite clear that in looking at them that the short chin/jaw is a far greater contributor to your profile concerns than that of the nose. Like many profile concerns, it is really a ratio of the nose:chin in looking at the deficiency and where the greatest improvement may come from what procedure. In your case I would put it at 80:20, jaw:chin. While chin augmentation will make a major difference, a rhinoplasty where the tip is thinned and a bit shortened will make for an even better result.
In many cases of rhinoplasty, the chin augmentation that may be done with it is complementary to the nose changes. But in your case it is the reverse…the rhinoplasty would be complementary to the chin augmentation.
Q: Dr. Eppley, I would like a more elongated lower 3rd of my face with less of a square look. I previously had liposuction done underneath my chin but it has never improved. Will the chin augmentation improve this area? Also, approximately how much length in mm is needed to achieve what I am looking for? Thank you!
A: You have a very distinct chin augmentation need. Your square jawline and distance between the base of the nose and the chin indicates that there is a vertical lower facial deficiency. I would not have expected liposuction under the chin to change what is a skeletal issue. There are twi fundamental approaches to managing a vertical lower third of the face deficiency. If it is just located anteriorly a vertical lengthening sliding genioplasty or a custom vertical lengthening chin implant can be used. If one feels the entire jawline is vertically short from front to back only a custom jawline implant that lengthens the entire jawline can be done. In looking at your face my feeling is that a vertical lengthening sliding genioplasty would probably be the best choice. In my experience at least a 7mm vertical increase is usually needed to make a noticeable vertical chin augmentation change. This is done by an open wedge bony genioplasty where the front edge if the bone rotate down while the back edge of the bony cut keeps the bone in the same position. The exact measurement of vertical chin lengthening needed can also be determined by two other methods. One can open their lower jaw to the vertical chin length that looks good to you and measure the created distance between the front teeth. One can also take measurements of their facial thirds and then see how short in millimeters the lower facial third is. I would do both methods to see how well they correlate so you can select the most effective vertical chin augmentation improvement.
Q: Dr. Eppley, I think my eyes are slightly uneven but I doubt anything can be done about that and that’s okay. I would like to change the prominent eyebrow structure from the center of my face extending to the outside supraorbital ridges. (brow bone reeduction) They are also slightly uneven. People often ask me if mosquitoes bit my eyebrows. The other thing that bothers me is my weak jaw line. I push my lower jaw out so its less obvious. (chin augmentation)
I know I will never look like a super model, its not even something that I want. I would just like a more symmetrical, angled, softer looking face. Thank you so much for your time and effort, Dr. Eppley. I hope it’s what you need in order to assess for possible procedures.
A: Thank you for sending your pictures. What they should is considerable brow bone protrusion from the glabella to the outer orbital rim. Even without x-rays I can tell that is due to significant frontal sinus hypertrophy and will require an osteoplastic bone flap setback technique for your brow bone reduction and not just burring alone to get a significant reduction. The brow bone protrusion you have is very similar to what I see in men with two distinct medial brow bone mounds. The slope of your forehead is also fairly retroclined and it would be ideal to augment the upper forehead at the same time to really change the entire shape of your forehead.
From a chin standpoint, it is both horizontal and vertically deficient in regards to being in balance to the rest of your face. While a sliding genioplasty would be the historic solution (due to the need for increased vertical chin height), my newer vertical lengthening chin implant (small size in your case) would work well as it brings the chin both forward and down. (at 45 degrees) This would a very good solution for you that is more cost effective than a sliding genioplasty with a much quick recovery as well.
Now that I know exactly what need to be done, I will have my assistant pass along the combined costs of the procedures to you on Monday.
Q: Dr. Eppley, I am interested in a chin augmentation and rhinoplasty after our consultation? What are the logistics of the actual procedure…i.e, time needed to recover, possible adverse short and long term effects, are the results permanent or will it need to be altered down the road to maintain its new shape, and are allergic reactions to the implant material common?
Another concern of mine is that I train in jiu jitsu (it’s like wrestling pretty much) so would the implant possibly be jostled loose if I were to get knocked in the chin? If so, would the sliding genioplasty yield similar results or no? I do like the chin implant.. just worried that it could be a potential problem.
A: The combination of rhinoplasty and chin augmentation is a very common facial reshaping surgery because of its dual benefits in changing two important areas of facial prominences. These are outpatient procedures done under general anesthesia. The most significant recovery is the first week when the nose will have a tape and splint dressing and the chin will be the most swollen. After the first week the nasal splint comes off so it is easier to be seen out in public without having had obvious surgery. Most of the swelling is gone by about three weeks after the procedure although it really takes a full three months before one should critique the results.
Both the rhinoplasty and chin augmentation create permanent effects through bone and cartilage modifications (nose) and the placement of a non-degradable implant. (chin) There is no such thing as an allergic reaction to a silicone implant although there is the rare occurrence of the risk of infection (1% or less) The chin implant will be secured in placed by small screws so between screw fixation and the enveloping scar that occurs around any implant, it will never move regardless of almost any degree of physical contact. You would have to break the bone to move the implant.
The biggest risks or need for revisional procedures for either a rhinoplasty or chin implant are aesthetic in nature…how does it eventually look and is the patient satisfied. The overwhelming reason for revision of any facial aesthetic procedure is the patient desire for additional changes/improvement in the shape of the nose or chin.
Q: Dr. Eppley, I have a weak chin making my side profile look really bad. I think its was because of a overbite. I have been wearing braces but I just want to have a good profile. Can I still get a chin implant? I don’t care about my overbite so I’m not thinking of getting jaw surgery. Will a chin implant with wings be a good alternative?
A: If mandibular advancement (orthognathic) surgery is not going to be done and of that you are certain, then attention can be directed to its aesthetic enhancement or camouflage. Chin augmentation can be done successfully using either a chin implant or a sliding genioplasty. Whether a chin implant is best for you depends on how short your chin is. Off-the-shelf chin implants do not exceed 10 to 11ms in horizontal projection so very short chins in men may be inadequately treated by a standard chin implant alone. I would need to see a front and side view picture of you to determine how successful a chin implant would be in your case. These pictures would be used for computer imaging to determine how much increase in chin projection is needed based on measurements and different changes in chin dimensions.
Q: Dr. Eppley, I have a question about chin augmentation. I am on Remicade for Crohn’s disease and was wondering if you have experience working with patients on Remicade and any recommendations you might have for them when undergoing chin implant surgery.
A: Remicade or infliximab) is a TNF-alpha (tumor necrosis factor alpha) blocker used to treat inflammatory bowel disease. (IBD) It is effective in Crohn’s disease and ulcerative colitis since IBD patients have more TNF-alpha in their systems than people without IBD. Remicade is usually given by infusion every 8 weeks. The best way to reduce the risk of infection or wound healing problems is to do surgery 6 to 7 weeks after their last Remicade infusion. Then have the next Remicade infusion 2 to 3 weeks after surgery. This balances the increased risk of infection versus the risk of a flare up of IBD symptoms.
Since chin augmentation surgery is a fairly small insult on the body, this approach may be unnecessary. But I have used it successfully in the past for cosmetic surgeries far more major than chin augmentation such as tummy tucks and breast augmentation.
Q: Dr. Eppley, I have this grinding type noise when I open my jaw on my right side. I have had orthodontic treatment years ago and have a underdeveloped lower jaw. I consulted my orthodontist about the grinding noise possibly being linked to my underdeveloped lower mandible. He told me that my jaws are lined up correctly and I should do nothing about this grinding noise. At the beginning if my orthodontic treatment a lower mandibular advancement was recommended, however I decided at that time that I would just have orthodontic treatment without surgery. After orthodontic treatment I have a clearly recessive jaw with extra skin around my lower jaw area. As a craniofacial and maxillofacial surgeon I would highly consider your opinion in what my next step should be.
A: Many people have asymptomatic grinding noises which emanate from their temporomandibular joints. This is usually caused by the disc in the joint which may catch on opening as the mandibular condyle comes forward. Underdeveloped lower jaws with Class II malocclusions (orthodontically corrected or not) have a greater propensity for these disc noises. But as long as one is having no pain in the TMJs or any difficulty with opening, there is no treatment indicated. For the recessive jaw and loose skin around it, this can be aesthetically addressed by either a sliding genioplasty or a chin implant. Either approach has certain advantages and disadvantages that must be assessed based on each person’s anatomy and aesthetic desires. The first place to make this determination would require an assessment of pictures from the side and front views.
Q: Dr. Eppley, I wanted to know if there was any way to make my mouth smaller. I am 22 years old and I have always been self-conscious about my mouth. It has become a major problem in my life. I want to know what kind of recommendations you might have.
A: To some degree you have a bit of bimaxillary alveolar protrusion which makes your overall mouth area project further out from the frontal plane of your face. This makes your overall mouth look big. Also, by pure measurements, the horizontal width of your mouth from one corner to the other is wide as it exceeds a vertical line drawn down from the pupil of your eyes.
One method to make a mouth look smaller is to narrow its width by bringing in the corners of the mouth. While this can be down, it does leave scars at the corners of the mouth which with your natural skin pigment will probably not be very good scars. Eve if they were good and acceptable scars I do not think that would help that much as your problem is as much a protrusive issue as it is about its width.
An alternative strategy to dealing with a protrusive mouth is to increase projection of other areas of your face to better balance the mouth. You do have a retrusive chin and flat cheek bones. Increasing their projection through chin and cheek augmentation will probably help make the mouth look less protrusive and create better overall facial balance. This is a scarless and safer approach to smaller mouth surgery. The potential benefits of improving these facial areas on the appearance of the mouth could be demonstrated by computer imaging.
Q: Dr. Eppley, I am a 26 years old female. I had a chin implant surgery along with a rhinoplasty three years ago. I was happy with the surgery results until I started to see how I looked in pictures. I think that my face looks too long, and in some pictures it looks really especially when I smile. I also dislike my gummy smile, though I can hide it when I try not to rise my lips. I don’t know what the problem is. What would be the most recommended procedure for me? I would like to look more feminine and balanced. Could a smaller chin implant make my face more balanced? are there any risks involved? Could cheek fillers or implants help? Or should I also consider the possibility of orthognathic surgery, in case the camouflage would yield very limited results.. What other procedure would you recommend for me? The upper part is me before the surgery, and the lower part is me after the surgery. And I also attached my X ray.
A: While both your rhinoplasty and chin implant augmentation produced good results, I see the crux of your facial concerns with the chin area. It is a very large implant which was needed but is also the source of your facial imbalance.
You initially have a very retrusive chin due to an underdeveloped lower jaw. When the chin is so short due to an underdeveloped ramus of the back part of the lower jaw, it is also vertically long anteriorly as the chin rotates downward. With a chin implant used for the augmentation, it does bring it forward but also actually makes the chin vertically longer and with a much deeper labiomental fold. A better chin augmentation would have been a sliding genioplasty. This would also bring the chin forward but it vertically shortens the chin and makes it more narrow, both changes which are more feminine.
Thus I would recommend that you replace your large chin implant with a sliding genioplasty that does not create as much horizontal projection but also vertically shortens it as well. It will also make the chin more of a triangular shape rather than have an obvious square shape to it that it has now from the outline of the implant. You may also consider adding small cheek implants to bring a little highlight to the cheek area, which with the genioplasty, would give your face more of a feminine heart shape to it.