How Can My Asymmetric Sliding Genioplasty be Fixed?

Q: Dr. Eppley, I’m 4 months out from having upper and lower jaw surgery. A 2.5mm upper advancement with a 4mm transverse expansion and 3mm posterior impaction to correct an anterior open bite, along with a 3.5mm lower advancement through a BSSO. In addition to this, I had a 7mm chin augmentation through sliding genioplasty. While everything else went perfectly well, unfortunately the genioplasty ended up asymmetrical.

I’ve attached both frontal and profile pictures for you here, as well as frontal and profile pictures from before the surgery. In addition, my latest panoramic x-ray is included as well. I’ve also included a picture of my sulcus as it was before surgery, and as it currently looks now, as well as a “relaxed lip” picture as I believe I show more lower incisors at rest than I used to. Forgive the photo quality…interestingly, I look much worse in photos than in 3-dimensions. I’ve never been terribly photogenic. In addition, I have a bit of residual swelling in my upper center face.

In any case, obviously, I’d like to have the asymmetry corrected (I think its very obvious). So, I have these questions:

1) How difficult is it to correct? My OMS seemed to be very reluctant to do a correction and implied it could be very difficult which is why I’m looking to you for correction based on several recommendations I’ve received about your work. Do you think I be better off with fillers or pre-jowl implants to mask the asymmetry rather than redoing the osteotomy? There are also those pesky “dents” on either side of my chin (pre-jowl)…

2) Is there a risk of more lower lip drop–greater than the first surgery? I did notice my lower lip dropped a little bit…perhaps 1-3mm though I can’t be completely sure as I never really looked at it before and don’t have any previous pictures of my lips in repose. It’s obviously not a devastating lip drop/incompetence issue as I’ve heard about. Do you see anything with the sulcus that looks abnormal in any way? Would an additional surgery in this area be more risky in this respect? If there is a problem…can it be corrected?

I’m planning on coming up there in the next 4-6 weeks for an in-person consult, but wanted to get an initial opinion from you as to what you believe needs to be done. 

A: Thank for detailing your surgery and sending your pictures. Now that you are four months out from surgery, you can see largely see the effects of the surgery as all of the swelling has subsided and the tissues hav contracted back done to the bones. What I see is the chin asymmetry and the very typical notching at the back end of the osteotomy sites which can occur from a sliding genioplasty based on how it is cut. (angle) Your lower lip position is hard for me to judge since how you are now is all I know. But I will assyme that there is a slight lower lip sag/ptosis.

In terms of improvement, two out of three issues are straightforward. First, the jawline indents will need to be filled in which can be done with either a shaped mersilene mesh overlay implant or a wrap-around prejowl silicone implant. (1mm thick in the middle so it adds no further horizontal augmentation) Second, since an intraoral approach would be redone the mentallis muscle would just be repositioned and resuspended not only as a prevention of any further sag but may actually improve where your lower lip is now. Lastly, the bony chin asymmetry can be delt with two ways, eitehr reposition the genioplasty or shave down the large or more prominent side. Since you may be getting an overlay implant anyway I would think burring the bone is far simpler. The only reason to reposition the genioplasty is if there are other dimensions to it you want to change. I suspect what has happened is that with the typical central plate fixation used, one side got rotated a bit (no lateral stabilization) and the asymmetry resulted. The genioplasty can be recut and repositioned without a problem (never confuse can with want to) but you just should have a godo reason to do so and to make sure that something simpler may not work just as effectively.

Dr. Barry Eppley

Indianapolis, Indiana