Q: Dr. Eppley, I have 2 questions about injectable brow augmentation and chin asymmetry.
1. Is it possible to create a more deep set (masculine) brow via fillers?
2. the bottom of my chin is a bit asymmetric. Can filler be used to even this out? Thank you for your time.
A: Inejctable brow augmentation and correction of chin asymmetry can certainly be done by using injectable fillers. It takes a fair amount of injectable filler to augment the brows, usually about 2 syringes. But it can create a significant brow augmentation effect. The improvement of chin asymmetry will take far less volume. While effective, like all injectable fillers, its effects will be temporary in the range of 6 to 9 months at best.
Injectable brow augmentation can be a very good initial ‘test’ to determine if overall brow augmentation produces a good result. If not it can always be easily reversed by hyaluronidase injections or simple the passage of time to let the filler resorb naturally. If one likes the result, one may progress to the use of fat injections or to a permanent brow bone implant. Permanent brow bone implants are made from the patient’s 3D CT scan and are usually placed through an endoscopic approach.
Dr. Barry Eppley
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
Q: Dr. Eppley, Approximately 15 years ago, I fell over and knocked my front two teeth out. Today, I suffer from cross-bite and a deviated chin during occlusion. It is quite apparent to me that my jaw has been shunted ever so slightly to one side posteriorly, and slightly superiorly also, this is the side to which my chin deviates. I believe that I could have had a unilateral condylar fracture which has subsequently healed in a dislocated position. Could you advise me as to what diagnostic modality could be used to evaluate a historical condylar fracture, or what factors may suggest a condylar fracture that has thus gone undetected. What methods can be used to correct this issue? Many thanks.
A: The best way to diagnose condylar position is a 3-D CT scan of the face. That will clearly show you the position of the condyles and the entire shape of the lower jaw. At this point you want to only correct the asymmetry through a chin osteotomy and midline realignment. The condylar position, regardless of where it is, is beyond changing at this point as lpng as one has a functional and good interdigitating occlusion.
Dr. Barry Eppley
Q: Dr. Eppley, I was born with a face that to me looks a little crooked. It seems my jaw line is shorter on one side and it looks like my face is bent in one direction. Would you be able to look at the pictures I am enclosing and please tell me what you think. My face is definitely not even and my chin is crooked. I think it is too big, but is it also receded? I am so self conscious that I hide behind my hair and makeup. Thank you so very much for your time and please, any advice and recommendations would be greatly appreciated!
A: I have taken a look at your pictures and your concerns. I think there is no question that you have facial asymmetry that is almost completely due to the shape of the lower jaw. The differences in the jaw length has resulted in frontal chin asymmetry with the midportion of the chin being deviated to your right side. This can be corrected (straightened) through a chin osteotomy, sliding it over to the left until its midportion is in alignment with that of your nose and upper and lower lips. This may also require some vertical chin adjustment with a reduction of the left side or an opening lengthening on the right side, depending upon which aesthetically looks better. Your side view shows a mild amount of recession which, given that an osteotomy would be done, I would take the opportunity to give more horizontal projection to the chin as well. I have attached some predictive imaging of the potential outcome with this sliding chin osteotomy procedure.
Dr. Barry Eppley