Would My Nose Look Smaller If I Had A More Defined Chin and Jawline?

Q: Dr. Eppley, I tried to get pics of my face to show my lower third facial deficiency. I live alone so had to use a selfie stick and tried to get different angles. Not too happy with my nose either but maybe it won’t look so prominent if I had a more defined jaw line. 

A: Thank you for sending your pictures. You did a good job with the selfie stick. You are correct in that your very short chin/jawline magnifies the size of your nose. When it comes to chin augmentation, all available options are on the table so to speak, each with a slightly different result. The best one in my opinion, due to the degree of short chin/jaw that you have is a sliding genioplasty with a chin implant overlay. Moving the chin bone out (not the whole lower jaw just the end of the chin bone) helps the neck a lot because it pulls out the attached muscles with it as the chin comes forward. It also serves as a bony foundation for the most of the chin augmentation and lowers the risks of just a large chin implant placed alone. The purpose of the chin implant overlay (small chin implant with long wings) is to primarily add some width to the chin at the back end of the bone cuts, which addresses the aesthetic problem of sliding genioplasties in some patients from making the chin appear more narrow from the front view as it comes forward.  In essence in challenging cases of congenitally short chins, this approach combines the best features of a sliding genioplasty and a chin implant…each of which has their own aesthetic limitations in the very short chin patient.

Attached is some imaging of you as well as an example of what the technique which I have described.

Dr. Barry Eppley

Indianapolis, Indiana

Can a Larger Chin Implant Be Replaced with a Smaller One? (Chin Implant Revision)

Q: Dr. Eppley, Would you need to see x-rays or any other studies to consider doing a chin implant revision?

Have you ever helped anyone in my situation where a larger implant simply needs to be replaced by a smaller one?

Do you have any specialist trained in ultherapy who has experience in treating excessive facial fat?

As I live out of state, do you ever do virtual consultation through Skype, plus photographs I could send so I would not have to travel there twice if I were to be a good candidate for the procedures?

Thanks again for your time and expertise.

A:In answer to your questions:

1) A 3D CT scan of the mandible/chin is always useful to see the position of the indwelling implant on the bone.

2) Chin implant revisions are very commonly done for size, style and/or implant positioning….as many people want their chin augmentation bigger as want it smaller.

3) My medical aesthetician specialist uses Exilis for the treatment of unwanted facial fat with good success..

4) My assistant Camille will contact you to schedule a virtual consultation time.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Chin Implant Be Replaced With A Smaller Better Looking One?

Q: Dr. Eppley, Three years ago, I went to a surgeon who said I needed a facelift, some fat injections in the cheeks and a chin implant for an “inadequate chin“. I told him I wanted some fat injections in the lips as well , but emphasized that I do not want my face to be longer because it was already too long . During the facelift, a medium-size, Medpor button implant was secured in the midline position with a number of 26 mm Stryker screws. It definitely made my face longer. In addition, from the side, the button implant curves out in a funny position, and there is some dimpling of the skin, but that was there before.

My goal is to take it out, and replace it with a much smaller implant that would not be screwed in, be in appropriate shape with the natural projection from the side.

I have frontal, AP , and lateral skull films on CD. The chin problem is definitely a part of the entire facial distortion.

If you have significant experience with revision of excessive cheek fat  injections, would be happy to learn more.

A: Thank you for your detailed surgical history and description of your current facial concerns to which I can answer the following:

1) While your existing chin implant can be replaced with a smaller one of a better shape, it will need to be screwed in as it will otherwise become malpositioned. (smaller implant in a bigger pocket) While an initial chin implant may be capable of maintaining its position due to the created pocket, such is not the case when downsizing a chin implant. (chin implant revision)

2) The best approach to excessive fat removal in challenging facial areas are energy treatments like Exilis or Ultherapy. While that is not the intent of these skin tightening devices, fat absorption is one of their well known adverse effects….which in  your case is a beneficial one. I have seen that successfully done many times.

Dr. Barry Eppley

Indianapolis, Indiana

Can Pectoral Implants and Abdominal Etching Help Achieve My Dream Body?

Q: Dr. Eppley,  I have attached pics of my torso, I am interested in filling my chest out, attached a dream perfect chest (not expectation) chest filled out, more flat than rounded, more square.  I will not proceed with that if I cannot also do liposuction for abdominal region, normal height, weight is  6’1″, 220 lbs, my current weight is 260 lbs.

GOALS: 

1) A properly proportioned “ripped” looking, filled out chest. (through implants)

2) A Slim waist from size 44 to size 33. 

3) A flat six pack ab stomach, by removing fat from upper and lower abdomen, flanks, back, and small area around pubic bone, 

4) Abdominal line etching if possible.

I am concerned about 1) activities that might cause the implant to shift. 2) activities for best results, food and diet, exercise, 3) activities that impair results, things I should never do, or can no longer do.  4) if i get fat, where would he fat show up? I live a healthy active lifestyle as far as my injuries permit.  I’m concerned about contraindications, (i.e. My blood pressure is 120/80, but controlled with 50 mg daily atenelol), I’m much less mobile than my college football days.  I cannot get the workouts I used to have. I want to properly fit into my clothes and wear designer suits. They do not make designer suits for a man 260 lbs.

A:Thank you for your inquiry and sending all of your pictures. The first comment that I can make is that we have to be realistic with what its possible. The use of adjectives like ‘dream perfect chest’, ‘ripped chest’, ‘slim waist’, ‘flat six pack abs’….these all end goals that are not going to be achieved with any form of plastic surgery with your current body shape. Those are not achievable goals with your current weight of 260lbs for sure and may not even be if your weight was at 220lbs.

Secondly most of the fat you carry in your abdomen is intraperitoneal not subcutaneous which is very typical for middle aged men. This is fat that can only be reduced by weight loss not liposuction. These are fat collections that are not accessible to liposuction removal around the abdominal organs.

Thirdly I would agree that the chest and abdominal components are linked. There is no aesthetic sense in getting pectoral implants if the abdominal projection is not less than or at least even in profile with that of the enhanced chest projection.

Unfortunately I can not be of any assistance until at the least the intraperitoneal fat component is reduced with substantial weight loss. This not only will create a better result but will also result in the need for less surgery to try and do so.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Lower Wisdom Teeth Be Removed at the Same Time as Getting a Jaw Implant or Should It Be Beforehand?

Q: Dr. Eppley, I’m looking into getting jaw implants and my bottom wisdom teeth extracted. I’ve contacted several surgeons who either say it can be done in one go or I would need to extract the wisdom teeth first before jaw implants. 

What would be your stance on this?

Is a week or a week and a half between wisdom teeth extraction and jaw implants too soon?

A: I will assume you are specifically referring to the lower mandibular third molars or wisdom teeth. As a general rule you should space these two procedures 3 months apart, a week or two is insufficient. Jaw angle implants have the highest infection rate of any facial implant. Why risk doing anything that would increase that risk factor further? It is not a question of whether they can technically done together, as they can. It is a question of the wisdom in doing so. I wouldn’t recommend doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Would Jawline Augmentation Make My Face Look Slimmer?

Q: Dr. Eppley, my concerns regarding my chin/ jawline/ lower portion of my face are related to my profile and front views. From the side, I would like my jawline to look more defined, thinner and projected forward horizontally and maybe vertically as well. From the front, I would like my face to look thinner. I feel that my face from the front looks bottom heavy, I have jowls and marionette lines, even though I’m 34 and I am not, nor have I ever been, overweight-  I’m 5′ 8” and weigh 128 lbs.

I’ve have had these issues even when I was in my 20s, so I think it is more an underlying lack of bone, chin is possibly too short and/or too recessed, than an actual aging issue. I also think I have fatty deposits in my jaw/chin/neck area.  I have looked into chin implants, sliding genioplasty, and neck/chin/ jowl  liposuction. I feel that while the research has helped me to better articulate my concerns, it also has me confused as to what treatments would be most appropriate for my specific case.

I have attached some current pictures to this e-mail of my face from different angles. Could computer imaging be done to help me understand the possible outcomes and what procedures would best suit my concerns?

A: Thank you for your inquiry and sending your description of your current facial concerns to which I can make the following facial reshaping comments:

1) While jawline augmentation would provide some improved definition, particularly that of chin projection and vertical jaw angle definition, i would have concerns that this may be a contraindication to the goal of also making your face thinner. By definition jawline augmentation adds volume to achieve its effect. While the jaw angle volume would be vertical and the chin volume horizontal, I have some concerns that this may still make our face ‘heavier’ due to your natural tissue thickness anatomy.

2) The real issue that you have with your fuller face is the thickness of your tissues and the jowl sagging that has developed. This is the main component to your face looking heavier. To achieve a more heart-shaped face, which I think is largely what you mean by a thinner face, your really need a jowl tuck procedure (mini lower facelift) with jowl defatting combined with chin augmentation. (which also includes getting rid of the submental crease indication. 

3) I would consider #2 the foundational procedure. I would stay away for now from any jaw angle augmentation as the last thing you need is anything that has a risk of making the lower third of your face heavier.

While on the one hand a lower ‘facelift’ seems incongruous with your relatively young age, it is what the tissues are doing anatomically that matters not their chronological age.

Dr. Barry Eppley

Indianapolis, Indiana 

Is a Fat Graft or Implant Better for the Correction of Enophthalmos?

Q: Dr. Eppley, I recently read something you wrote from this website Real Self on recommending an implant for the correction of enophthalmos. I was wondering if you could explain your preference over using an implant instead of fat. I was also wondering if you could clarify whether a risk of filling that area with an excess amount of fat could potentially cause proptosis. Thank you very much in advance.

A: Fat injections are less well uncontrolled in terms of placement and only have a soft push on the structures that need to the lifted. In addition how much volume do you need to correct the problem, over- or undercorrection is as likely as the right amount.  A custom orbital floor-rim implant is made from the patient’s 3D CT scan where the exact anatomic differences between the two sides can be determined down to the 0.2mm level. It is the best method of true skeletal correction if that is the goal.

But the treatment plan for each enophthalmos case must be determined on an individual basis.

Dr. Barry Eppley

Indianapolis, Indiana

Will A Vertically Lengthening Bony Genioplasty Help My Lower Lip Problem?

Q: Dr. Eppley, I thought it might be possible to have some form of genioplasty, sliding the chin down slightly to lessen the angle of the chin from the side. I thought moving the chin down slightly might reduce the amount of compression of the lower lip. As for the alignment of the lips I thought I might use a fat transfer or filler  to align the lips. (at a later date)

A: Your concept of moving the bony chin downward (vertical lengthening bony genioplasty) to try and drop the lower lip down with it is one that on the surface makes anatomic sense. In theory one would think there would be some relationship between the bottom position of the chin and the position of the lower lip. However in dong many vertical lengthening chin osteotomies with interpositional grafts, some up to almost 20mms, I have yet to see the lower lip pull down. (which is actually a theoretical concern about vertical chin lengthening) What that is good news for those patients with normally positioned lips, it may not be good news for someone who has your lip positional issues and is trying to change them. However I am quick to add have I ever done this operation in someone with your specific lower lip issues with that being goal.

Such an operation only makes sense for you if there is an aesthetic reason to vertically lengthen the chin. Then even if the lower lip position is not improved there would still be benefit from the surgery. In your face that is already long and narrow, such an aesthetic change would not seem beneficial.

Dr. Barry Eppley

Indianapolis, Indiana 

Should I Lose Weight Before Having a Sliding Genioplasty and Neck Liposuction?

Q: Dr. Eppley, I have three questions regarding the combined sliding genioplasty and neck liposuction procedure.

Would my recovery be much more extensive than with a chin implant?

I’ve gained about 20 lbs over the past few months. If I lost that weight, would I still need the neck liposuction?

And at my age, is it better to do neck liposuction or neck lift?

Thanks again!

A: In  answer to your questions:

1) A sliding genioplasty has some increased ‘recovery’ time from a chin implant but six weeks later that is an irrelevant issue.

 2) Since I don’t know what you looked like 20 lbs ago I can not say. But there is always one way to find out….don’t do the surgery until you lose the weight. That would be the best approach.

3) What you are referring to is the option between neck liposuction alone vs a submentoplasty (neck liposuction + muscle tightening). In fuller necks  a submentoplasty always produces a better result than just liposuction alone.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Slipped 10th Rib Be Removed for Pain Relief?

Q: Dr. Eppley, I have bilateral slipping ribs at 10th level. My 10th rib has been slipping under the ninth and causing considerable pain for eighteen months. I am interested in a qualified plastic surgeon performing this procedure vs.a thoracic surgeon. I have yet to find a surgeon who has ever performed this procedure. Thank you for your time.

A: Thank you for your inquiry. When you refer to slipping of the 10th rib, you are likely referring to the cartilaginous end of the 10th rib where its distal end comes around to attach to the subcostal ribcage. That end of the rib is usually not fused to the ribcage and has some mobility in most people but that his usually asymptomatic. If it is excessively loose or mobile that can a rare source of pain in some people. That portion of the rib can be removed to eliminate the movement of that portion of the rib. I have performed that subtotal rib removal before as well as for other rib pain associated cases like the costo-iliac syndrome patient.

To determine of this or any other type of rib procedure would be beneficial, it would be helpful to see an actual drawing on your ribcage of where the exact location of your pain is so I have a clear anatomic understanding of it.

Dr. Barry Eppley

Indianapolis, Indiana