Your Questions
Your Questions
Q: Dr. Eppley, about six months ago I had a medpor chin implant inserted through an intraoral incision and secured with screws. Unfortunately, the wings were too large and malpositioned. I had a revision one month ago in which the implant was removed, trimmed and re-inserted. Now the implant is the right shape and size, but my lower lip feels shorter and tighter. The top halves of my lower teeth show with the lip at rest, and I can barely raise it enough to cover them. When raised, the lip is lower in the center than at the sides. After the original surgery I had the same problem but not as bad, and the lip eventually went back to normal. This time the lip seems worse, and I’m worried it might stay this way. My Dr. said getting the medpor implant out was “very difficult” and it took twice as long as he expected. The implant actually broke when he took it out and he added 2 extra screws to hold it together when he re-inserted it. My chin and lower lip where very swollen for two weeks afterward and the center of the lip is still slightly numb. I’m worried I might have a problem with my mentalis muscle. Does my lip issue sound like something that will go back to normal on its own or like something that will require correction? Thanks for any advice.
A: In your history you have said the key words…intraoral incision. When using this approach for chin augmentation, the superior bone attachments of the mentalis muscle are cut and have to be resutured at the end of the procedure. Besides the numbness,, it is common to have some lower lip tightening and little tethering until the tissues heal and relax again. Going through the muscle twice, particularly in a more extensive revisional procedure, traumatizes and scars the muscle again…making symptoms of tethering and lower lip retraction more significant. It is too early to tell whether this problem is temporary or permanent. If it has not significantly improved by three months after surgery then I would recommend a mentalis muscle v-y lengthening and resuspension procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: So I wrote to you a few weeks ago. I had an implant placed and then removed after 4 weeks. The doctor said he didn’t remove bone structure but he did. My chin bone is round now instead of the two points (square) I had before, which I loved. He said he wasn’t removing bone structure, I can’t believe he did for a silicone implant. I wish he told me he was doing that and the side effects, I wouldn’t have done it. I liked the shape before. The implant was a huge mistake and I have stippling now after 4 weeks of removal. Can you fix that? Is there anything that can be done permanently to repair the orange peel/stippling? I was mostly scared of getting hanging skin, but this is way worse.
A: There would be no reason to remove bone structure when putting in an implant. What you are seeing is the remaining capsule/scar tissue that surrounds an implant after its removal. That combined with the extra or stretched soft tissues that has been created will make for a rounder chin appearance. It will not return exactly like it was before. Some of these effects, including stippling, will get better with time (months) as the tissues settle and much of the capsule eventually goes away since it has no reason to be there. But it is unlikey your chin will ever return 100% to the way it was. It will get a lot better with time as scar tissue softens but there is no magic to do now to help the problem..short of putting back some form of a chin implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in getting either a new chin implant or modifying the one I have. I had a Medpor contoured two-piece chin implant with 7mm (medium) projection placed about one year ago. While I like how much projection it has given and its front shape, I feel it is not adequate as it goes around the side of my mouth below the corners. I would like it fuller in this area but I don’t want a square chin implant shape either. I still want it contoured. What do you recommend?
A:I have taken a careful look at your existing chin implant’s dimensions and your desire for more lateral fullness as the implant crosses a vertical line below the corner of the mouth. In most patients that is going to be about 30 to 35mms from the midpoint of the chin back along the jawline. Your current implant has a thickness of about 4.9 mms (.7 of total 50mm wing length x 7mm central thickness) in this area as it tapers posteriorly. Switching to a larger projecting implant (9mms) will only make about a 1mm difference (5.7mm) in this prejowl area. A different style chin implant of the same central projection will not produce any larger fullness in this area. (4.5mms) Therefore, it is my advice to not consider changing the implant as no current chin implants styles make for increased fullness in this area without adding more horizontal projection. One option to consider, which is actually easier, is to keep the existing chin implant and place ‘shims’ underneath the implant in these areas. Shims are wedges of cut material that are slid underneath the indwelling implant that can provide more fullness to the implant in this area than it otherwise has. Since you have a Medpor implant, I would use double-stacked 1.5mm shims to accomplish this implant modification.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a chin implant done on 2/1/2011. It was a 7mm projection Mettleman style. The right side looks wonderful and I cannot feel the implant really at all. On the left side, however, the implant traces nicely along the edge of the jawbone until aproximately the last 8mm of the wing. At that point it swings upward at about a 40 degree angle. The wing can be felt intraorally with my finger near the bottom of my mouth on that side. Aesthetically, on that same side, there is a jowling effect. I do not know if this is due to the free floating wing or if the wing has pushed other tissue upward and created a lump or ball. My surgeon has suggested that we wait 6 weeks and then go in intraorally and either “tuck” the wing back under the periosteum or simply snip it off IF it is beyond the point of the pre-jowl sulcus, thus accomplishing the pre-op goal of filling in that area. He described it by saying that that what is now the “floor” of the pocket where the wing is malpositioned will be the “ceiling” if we tuck it back under the periostium. I believe he would suture the ceiling so as to ensure the wing doesn’t communicate with the previous pocket and again migrate north. Does this sound like a reasonable plan to you?
A: With today’s extended chin implants, exclusively those made out of silicone, the most common complication is wing malposition. The ends of the silicone implant wings are very thin and easily bent or folded onto themselves if the pocket made during surgery is not fully developed and extended enough to accommodate the full length of the implant. Because you can feel the end of the implant in the vestibule at the side of your mouth,it is bent up in that direction which also causes an implant to create a bulge in the jowl area. There are several approaches to fixing the malpositioned implant wing. The intraoral approach is one and is the easiest. The implant can also be removed, the pocket extended and replaced but involves ‘more surgery’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I had submental chin implant revision surgery and lipo under the chin. The incision was made in my natural crease and is extremely apparent. Also, it seems as though after the surgery, I have jowls that I have never had before. People think I lost a lot of weight. Is there anything that can be done to correct either situation reasonably? Thank you for your time.
A: The placement of a submental (under the chin) incision for chin augmentation is a fairly simple and straightforward consideration. Most people have a skin crease on the underside of their chin and this is a logical incision location. But depending on the location of this crease and the size of chin implant to be placed, this may not always be a good location. The chin skin stretched forward due to the push of the implant and what was once a hidden location may become more visible. For this reason, I often move the incision location slightly behind the submental skin crease to avoid any potential that it may become visible. Once the incisional scar location is set, there is no way to relocate the scar.
The development of jowls after chin augmentation may be the result of the wings or sides of the chin implant. Chin implants today are more anatomic in design and often will have long extensions that go back from the sides of the chin into the body of the jaw. If these wings get folded unto themselves and are not fully extended due to a pocket dissection that was short, the folding of the implant’s wings could create the look of jowls. If this is the problem, it can only be resolved by revisional chin implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I read your article where you speak about chin implants and you say: “Lateral or wing malpositioning is actually the most common problem and is a result of the newer styles having thin and more floppy wing extensions which can easily fold onto themselves” . I would be most grateful if you could advise on the best way to correct misplaced wings on the side of the jaw.
A: Unlike chin implants of old, most contemporary chin implant styles are more anatomic in design and shape. This means that rather than having a simplistic button or oval shape that just sits on the very end of the chin bone, they are longer and wrap around the bone to flow more confluently into the body of the mandible. This gives them long wings or lateral extensions along their sides. With silicone chin implants, these wings have thinner material thicknesses that end in minute paper-thin extensions. Because silicone is flexible, this makes them prone to fold upon themselves or buckle if the implant pocket is not dissected far enough back. Also they can ride upward or downward based on the angulation of the pocket dissection. Either way, these implant wing malpositions will be felt or seen as a lump or bump along the jawline. With Medpor chin implants, these wing malformations do not occur as the material is much stiffer and not flexible so the ends do not bend.
With chin implant wing malformations, the only way to correct them is to do an open revision. The implant is removed, the pocket checked and dissected further if needed and the implant then re-inserted. In some cases, the fine ends of the wings are removed as they serve no volume or contour purposes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a chin implant placed crooked (right side is out and left side is in). I had 2 revisions by the same doctor through the same incision under the chin. The doctor argued that I have face asymmetry but he agreed that it is not apparent from the photo before the surgery. Would you be able to help?
A: Asymmetry of the chin after chin implant surgery can happen for a variety of reasons, all related to the positioning of the implant. The implant can be centered off of the midline. Most chin implants have a central vertical line on them which should be matched up with the dental and facial midlines (central chin point, vertical line dropped down from the junction of the two lower central incisors) as well as the midline of the chin bone. Should this matching not be aligned, the implant may be shifted more to one side than the other causing an asymmetric chin. This is what I call a central chin asymmetry. The other reason for asymmetry can be with the wings of the implant. Today’s chin implants, particularly those made out of silicone, have very long and flexible implant wings that go fairly far back along the lower border of the jaw. Should one of these wings get folded onto itself or twisted, a bulge over the tail may occur and can cause lateral chin asymmetry. Similarly, it is also possible that the pockets dissected for these wings is at different levels along the edge of the jaw bone. (and maybe even off of it at the very end) This will cause of the sides of the chin to be less full than the other.
Given that you have had two revisions, you would think that if any of these problems existed they would have been identified and corrected. They may still exist, however, particularly in the tail of the implant which can be hard to recognize. It would also be helpful to know what type of chin implant you have in place. As it may have been modified in some fashion for fit and this may be a source of the problem as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q : I had a chin implant 9 years ago, when I smile its seems to be without form, like flat. And after X-rays I noticed that the implant is placed higher up where it should be (close to my teeth). A doctor told me it would be very laborious, because it would be two operations, one to remove the chin implant which would remain a hole, wait 3-6 months to heal the skin and the second to put the new implant from under the chin. Is there another solution? Thanks!
A: It is very common to have a chin implant that ends up being positioned too high on the chin bone when it is placed from inside the mouth and is not secured with a screw. When the implant is too high on the bone, it loses some of the projection or forward position of the chin that it would otherwise have.
Replacing a misplaced chin implant is fairly easy and can be routinuely done in a single operation. I have never heard of having to do it in two operations nor does that make any biologic sense to me. Going through a small submental (under the chin) incision, a new lower pocket can be made, the old implant removed, and a new chin implant placed and secured. In some cases, I have left the old chin implant where it was and just placed a new one beneath it. If someone has a deep labiomental crease, keeping a ‘spacer’ (old implant) high can help push that area out and prevent it from becoming deeper.
Dr. Barry Eppley
Indianapolis, Indiana
Q : Hello Doctor, I had a chin implant in November 2008. It got infected and had to be removed two weeks later. Now after one and a half years later my chin is still loose and stretched, making my chin look like it is hanging and looks weirdly different. I like to find out if there is a way of fixing this by shrinking and tightening my chin that will hold my face together the way it was before. Thank you for your time and help, hope to hear from you very soon.
A: In placing a chin implant, it is necessary to lift the mentalis muscle off of the bone. Like placing a breast implant, this stretchs the overlying tissues out. As a result, if chin implants are ever removed there is a risk of the tissues not shrinking back down and become ptotic. (sagging off the bone) This is a well recognized chin problem whose occurrence is more likely the larger the chin implant that was used. The risk of chin sagging is also greater if the pathway in which the chin implant was originally placed and removed was done from inside the mouth. (this method separates a greater amount of mentalis muscle)
Chin ptosis, also known as a ‘witch’s chin’ deformity, can be corrected through two different methods. If you want to get the effect of greater chin prominence that you were originally after, replacement of a new chin implant or moving the chin bone forward (chin osteotomy) can be done. This will give more chin projection and pick up the sagging chin tissues. If you are not interested in any further chin projection, then the mentalis muscle must be shortened and tightened to readapt the soft tissues back on the chin bone. This can be done either from inside the mouth using resorbable bone anchors or from an incision on the underside of the chin. (submental tuckup)
Dr. Barry Eppley