Cheek Augmentation

Q: Dr. Eppley, I am interested in numerous facial reshaping procedures including cheek augmentation. I think my chin is too big, my cheeks are flat and my nose could have a better shape. I have attached some pictures for your review. What do you think about these three facial areas in me?

A: Thank you for sending your pictures. From a chin reduction standpoint, it appears you have too much horizontal projection. Your chin can be reshaped by a submental approach where it is horizontally reduced and the sides tapered in so it does not end up looking wider. The cheek look you seek is a classic ‘apple cheek’ look that many females want. You have a very visible submalar concavity, probably due to buccal fat atrophy/deficiency, which gives yours cheeks an hourglass appearance as opposed to a fuller more convex anterior shape. You need a combined malar-submalar shell type cheek implant for your cheek augmentation which places the implants anteriorly to help achieve that type of cheek augmentation look. As to your nose, I would need more information as to what changes you seek as I see no obvious or glaring nasal shape deficiencies.

Dr. Barry Eppley
Indianapolis, Indiana

Sliding Genioplasty

Q: Dr. Eppley, I have a large chin button and excess soft tissue padding as well. My oral surgeon plans to slid the chin button (sliding genioplasty) during a jaw surgery but can you reduce the soft tissue afterward? Does this sound reasonable?

A: In interpreting your question, I assume you are having a sliding genioplasty done with a sagittal split mandibular advancement osteotomies. Having a large chin button implies that there is a bony knob on the end of the chin. Onto which you are saying there is a large soft tissue chin pad on top of this chin button. Your question then implies there may be an excessive soft tissue prominence of the chin after the sliding genioplasty is done and whether this can be reduced secondarily. While I would think it can that is a statement made without any knowledge of what your chin looks like or what the lateral cephalometric x-ray shows before the surgery. (how thick does the soft tissue chin pad appear) While this would be an unusual sequence of chin procedures (sliding genioplasty followed by secondary soft tissue chin reduction), for now let us assume it is appropriate to be done.

Dr. Barry Eppley

Indianapolis, Indiana

Lip Implants

Q: Dr. Eppley, I am interested in getting a chin reduction in the near future. However, I have been considering having lip implants (Permalip) before surgery on my chin. I was wondering if the implants would in any way hinder a chin reduction surgery? Would it also depend on whether an intraoral method was used? Thank you.

A: You are correct in making the connection between lip implants and intraoral chin reduction surgery. If you were having a submental type of chin reduction (an incision done on the underside of the chin) then having lip implants done at the same time would not matter. But if you were going to have the chin reduction done intraorally it would be advised to either do the implants at the time of the chin reduction ( chin reduction first and the lip implants as the second part of the procedure) or afterwards… but not before.

Permalip lip implants can be an effective and permanent method of lip augmentation. But they require careful placement in the lip tissues and should not be disturbed by traumatic stretching after their implantation until well healed. Thus it is best that they be surgically placed after other oral or facial procedures have been performed.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction

Q: Dr. Eppley, We had previously discussed that a button chin implant would be an option for me if I wanted to make the bottom of my chin appear less squared off.  I tried the filler as you suggested and actually really liked the rounder/pointier shape… but since I feel like my face is already long, adding that vertical height to create the pointer shape wouldn’t be my first choice.. 

1) Would it be possible to do something similar with a chin reduction technique so that the chin becomes somewhat narrower/rounder/more feminine and maybe slightly reduced vertically (vs an implant or filler that would require augmentation to add that shape onto my chin)?

2) Would it be possible to do this from an intraoral incision?  I saw examples on your blog using an intraoral approach as well as submental and wasn’t really sure what category I’d fall into… 

3) If an intraoral approach is possible, what are common complications/complaints you see or hear the most from your patients? Are any of these permanent?

A: In answer to your chin reduction questions:

  1. A chin reduction can reshape the chin, making it less square and reducing the vertical height.
  2. To do it intraorally, it would have to be an osteotomy technique where a wedge of bone is removed from the middle of the chin. This keeps the bottom of the soft tissues attached to the bone so there is not ptosis or sagging afterwards.The submental approach is simpler but does involve the scar on the underside of the chin.
  3. The intraoral approach will involve a slightly longer recovery and will create some temporary numbness to the chin and lip. Such numbness if not usually permanent in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction

Q: Dr. Eppley, I had a chin reduction three weeks ago. My chin always made me feel self conscious because I felt it was too long and wide for my face. Also, I had a dimple in the center of my chin that also really bothered me. My surgeon preformed a sliding genioplasty and shortened by chin 5mm. I was also concerned of the width of my chin after surgery so he tapered the sides of my jaw/chin to create a more narrow appearance.

I understand that there is considerable swelling still but I am so unhappy with how I look at this point I can’t even leave my house. The first thing I noticed was instead of dimple being in the middle of my chin, it’s at the very bottom and looks much deeper. I thought my dimple would be greatly diminished if not gone. This is what he told me. Also, my chin looks incredibly round. I feel like he should have addressed my skin and tissue instead of just addressing the bone alone. The sides where he burred to make it more narrow have this big hard knot or bulge on each side. What is this? When I smile I feel like I look awful. My lower lip looks thinner and is still numb. My lips when I smile look lopsided as well. I absolutely hate everything about my chin. I want a v shape appearance with my dimple gone or at least diminished. Now I feel like he made everything worse.

I want you to preform a revision but how long would I have to wait? I have included some pictures from 2 days ago. I would love to have a skype interview with you ASAP.

I appreciate your time and I look forward to hearing from you!

A: While I lack some specific information about your exact chin reduction surgery (type of osteotomy), I can tell you some very specific information about the recovery process from any type of reductive chin surgery. While three weeks seems like an eternity, the full recovery from chin reshaping takes a full three months, The swelling from chin osteotomies can be massive and, at three weeks, I would expect considerable chin distortion and roundness and it may not even be back to its normal size yet. Between resolution of the swelling AND soft tissue contraction back down to the smaller reshaped bone, it really does take a full three months. Other issues such as hard knots/spots, lip numbness and abnormal lip movement and smile are also normal at this point and will take the three months or longer to completely resolve.

If I am to interpret your pictures correctly, I believe some of them are before surgery (glasses) and the after surgery are those without. Based on these pictures I see a chin that do not considerable abnormally enlarged at this point after surgery.

From a chin dimple standpoint, No bony surgery is going to change the dimple. Its location may change because of the bone reduction but it will not go away. This is due to the fact that a chin dimple has a soft tissue etiology not a bone one. To decrease its appearance requires soft tissue management such as fat grafting.

The type of osteotomy used will determine whether a more v-shape will be the final result. This almost always requires a combined horizontal osteotomy and vertical ostectomy to achieve that change. I obviously have no idea what type of chin osteotomy was done in you although I am suspicious that it may have been a horizontal one only with some shaving on the sides. This does not usually work that well to effect that change. A simple panorex x-ray would answer that question.

Based on the chin osteotomy type and the presence of the chin dimple would determine whether staying the course until complete swelling has resolved would be best or whetehr earlier intervention would be more appropriate.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry

Dr. Eppley, I am interested in facial asymmetry surgery. I have an an asymmetrical face due to irregular growth of the jaw bone. Will the chin reduction on the right side correct it? I also notice that the right side of my face has less soft tissue so will the jaw angle implant balance out my face? Thank you.

A: Your facial asymmetry correction surgery approach certainly appears to be the correct one. Based on your pictures, the right side of the chin is longer and the width of the right jaw angle is more narrow than those two jawline areas on the left side of your face. So a right vertical chin reduction and right lateral width jaw angle implant should create improved facial symmetry. The only question is whether one wants to make the judgments for the amount of vertical chin reduction an the amount of width needed in the jaw angle up to the surgeon’s aesthetic sense or whether to make a more scientific quantitative assessment of them. That may be best done using a 3D CT scan or, at the least, get a panorex and lateral cephalometric x-rays to make some preoperative measurements.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction

Q: Dr. Eppley, I am interested in chin reduction surgery. Here are my questions:

1. What is your recommended approach for me…burring down vs. cutting the bone, intraoral vs. submental, etc? Just the chin or the jaw also? Changes to the fat/muscle/skin?

2. What can it achieve (can you simulate it with a digital image)?

3. What are its limitations and possible side effects?

4. What are the risks and how do you minimize them?

5. What can I do to ensure the best results possible? Are there limitations on travel?

6. Can you share before/after photos of women who have undergone this surgery?

7. Your site states $6500 for chin reduction – does this include anesthesia, operating room, surgeon’s costs? Does the cost differ by surgical method?

8. How much time to I need to plan to take off work and/or work from home?

9. How many trips would be required? (pre-op, surgery day, post-op/follow up?)

10. Would you recommend doing rhinoplasty and chin reduction at the same time or separately?

11. What are your Care Credit terms (6,12,18 months no interest?)

12. Do you require dental x-rays or some other type of imaging?

13. Would liposuction be effective in achieving a more defined chin/jawline? Is this considered a separate procedure from the chin reduction? Is there enough fat in your estimation that re-injecting it to my cheeks would produce a good result? Would  a future pregnancy alter the results?

A: Thank you for sending the detailed questions about chin reduction. My answers to your questions are as follows:

1) If vertical chin reduction is all that is needed than an intraoral wedge bony genioplasty approach would be used (this would include narrowing the chin  if desired) But all other chin dimension reductions are best done by a submental approach.

2) Computer imaging is always done before any facial reshaping procedure. Chin reduction is no exception.

3) Scar (if submental approach is used), asymmetries, uneven jawline, soft tissue redundancies are all potential risks and complications from chin reduction surgery.

4) As you can see in #3 the risks are essentially aesthetic in nature. Knowing how to manage the soft tissues in a chin reduction is actually more important than the bony reduction part of the operation.

5) Preoperative choice of the correct chin reduction procedure is the most important step to ensure the best result.

6) Because of patient confidentiality, there are very few before and after pictures that can be shared. And this is coming from someone who has done a lot of them.

7) This is a logistical question for my assistant Camille. Until we know the exact chin reduction procedure she can not give you an absolute number.

8) Recovery is all about the swelling and when you feel comfortable being seen in public. Everyone is different in that regard. It could be one week for some and three weeks for others.

9) One trip for the surgery is all that is needed. All followups can be done electronically.

10) Rhinoplasty and chin procedures are commonly done together. That is a personal choice.

11) Another economic question for Camille.

12) No preoperative x-rays are needed unless one is getting an intraoral bony genioplasty.

13) Liposuction rarely, if ever, can make a more defined jawline. Such changes are a reflection of what happens to the bone not the soft tissues. Any fat injections done would need a harvest site not from the neck. The amount of fat needed exceeds what can be obtained from the neck. Chin reduction surgery will not be affected by pregnancy.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Reduction

Q: Dr. Eppley, I had a chin and jaw reduction ten days ago. It went well except that I have had worsening swelling each day after surgery.  Today, when I woke up with even larger swelling on the left, I went to the ER to check it out and the ER doc after examining me was concerned I had a hematoma or an infection and ordered a CT scan with contrast.  When the doc came back to my room he said the CT showed a large abscess on the left and a smaller one on the right and said I needed to get them drained. Then he consulted another plastic surgeon in the ER who looked at the CT and then called my plastic surgeon to consult him.  After consulting each other it was determined these were pockets of liquid that can be a complication of surgery and would eventually be reabsorbed so no need for drainage.  One determining factor was my WBC was normal however I just finished up my antibiotics yesterday. Also the ER doc sent me home on another week of antibiotics so I am wondering if he isn’t still somewhat concerned about possibility of an infection. So nothing is going to be done about the liquid pockets and the large one on the left is particularly bothersome and really has me concerned not only about the possiblity of infection as well as it is delaying my progress with recovery (worsened the swelling, discomfort, etc). 

I know that you do a lot of jaw reduction surgery and would so appreciate to get your opinion re: these pockets.  Should at least the large one be drained to reduce chance of infection and speed up my recovery?

A: Since you are within the first few weeks after surgery, these fluid pockets are either blood, serous fluid or a combination of blood. Bone when it is cut can ooze after surgery since it is hard tissue that does not have the capability of soft tissue contraction around the oozing exposed blood ‘channels’ and relies on compression of the overlying soft tissue on the bone (external wrap), an indwelling drain to pull off the fluid or just naturally stopping on its own. (which it may do if the bone removed is fairly superficial) Probably every facial bone reduction procedure gets a little bit of fluid which just naturally resorbs on its own within the first month after surgery.

Large (and it can be debated as to what constitutes large) pockets of fluid do have an increased risk of infection (good bacterial culture medium), can be uncomfortable when big enough and can prolong the recovery of one’s appearance and the final result because of increased resorption time. Draining them by needle aspiration or opening the incision and suctioning the fluid out can provide a prompt resolution to these concerns.

I can not tell you what you should do since you are not my patient for this surgery and that is between you and your surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction

Q: Dr. Eppley, I am seeking a sliding genioplasty or chin reduction revision. After a sliding genioplasty 18 months ago and two bone burring operations to reverse it (6 and 12 months after the original surgery) there are still areas of bone, on either side of my chin, that were not shaved back to create my original narrow shape. I am left with a wide bulky chin, the excess skin and tissue have sagged from over the past year. Now, after my most recent operation, I have even more tissue. I am always advised to go back to the trio of surgeons who did it but after this I really do not want to. There is a huge miscommunication and when they discuss things in Spanish, in front of me, I no longer trust them. I just want to have my normal looking chin back. Do you perform this type of revision and reconstruction surgery? How often?

A: While you did not state exactly the method by which your two chin revisional procedures were done, I suspect they were by an intraoral bone burring method. While you should have had the sliding genioplasty reversed by redoing the osteotomy and setting back where it once was, intraoral bone burring was destined to create exactly what you have now…a broader flat chin with soft tissue excess. The proper solution now is a submental chin reduction technique where the chin bone can be narrowed and the excessive chin soft tissue removed.

This is a sliding genioplasty and chin reduction problem that I see and treat regularly. It would be helpful to see some picture of your chin and to know the exact details of all three of your prior surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction Options?

Q: Dr. Eppley, We are interested in chin reduction for our daughter. She is now 17 years of age. Through her orthodontist we have been told that she wiuld need a chin reduction. We have been to visit a plastic surgeon in our local area who is willing to operate on her but we would like to find someone with your level of expertise. We would like to what your thoughts are on what type of chin reduction surgery should be done. I have attached some pictures of her for your assessment.  Many thanks.

A: That you for sending your daughter’s pictures which is extremely helpful. She has an unusual excessive chin problem as it is very horizontally protrusive but also vertically short. This creates a prominent chin ‘knob’ deformity. While I don’t know what the bone looks like underneath (it would be helpful to see a lateral cephalometric x-rays from her orthodontist who undoubtably has one) her excessive chin problem is both a bone and soft tissue issue. Both have to be addressed to produce a satisfactory chin reduction result, removing soft tissue alone will not work. While the bone may be horizontally excessive, her chin is also vertically short. Her entire lower face is actually vertically short compared to the rest of her face. Ideally you would want to convert the excessive horizontal bone to increased vertical chin height. This would stretch out some of the horizontally excessive soft tissue which is just following where the bone is. Then any excessive soft tissue could be removed. While this may be the ideal approach, it would entail two stages to do so. The other approach would be a one-stage submental chin reduction with removal of excessive horizontal bone which would then allow some of the excessive soft tissue chin pad to be removed and tucked under. This would still leave the chin vertically short but would offer significant improvement in a single surgery.

Dr. Barry Eppley

Indianapolis, Indiana