Your Questions
Your Questions
Q: Dr. Eppley, I am committed to undergoing chin augmentation with an implant but I am a little anxious. I just have a few questions. What do you see as the risks involved with a chin implant procedure, if any? Do your predictive photos mirror actual results? Thanks for taking the time to answer my nervous questions.
A: In answer to your presurgical jitters:
1) There are always some risks with any surgery and chin implant augmentation is no exception. Fortunately those risks with chin implants are few and very low. The ones that I have observed are infection (1% to 2%) and asymmetry of the wings of the implant. (2% to 3%) Both are very correctable, albeit with a revisional surgery. There is always the risk of too little or too much chin augmentation with an improper size implant but that is not a very common problem in my experience.
2) Computer imaging is an estimate and not an exact predictor of the final outcome from any plastic surgery procedure. Its predictive ability varies based on the type of procedure being performed. Of all the facial cosmetic procedures, chin augmentation is one of the more accurate in terms of predicting the outcome as it is a profile or silhouette facial feature.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I am 34 years old and in the past several years I have noticed quite a lot of sagging in my mid and lower face along with volume loss. Cheeks have gravitated downward, neck sagging and my eyes have hollows under and around them. I see much of the same in my mother. I have researched many plastic surgeons this past year and have heard only great things about you online! I am most concerned with sagging in my lower face, neck and around cheeks. I also would maybe like to add some volume to lips especially from a profile view. And one more thing, my ear lobes tore several years ago from scabbing due to hypersensitivity to earrings so I would like to have ear lobes repaired as well.
A: I have taken a careful look at the pictures you have sent me. As you know you are fairly young for any major procedures and you really don’t need anything too drastic. But I can see your concerns about having an overall tired appearance. There are several things I might consider for some structural improvement. These would be the following: small cheek implants to lift the midface and fill out some hollowing, small chin implant for more chin projection and to improve the jawline, and liposuction of the jowl and neck for a little contouring and skin tightening. I think if you can just ‘slenderize’ your face a bit and give it some more structure or angularity, it will look more youthful and rested. You most certainly don’t need anything done around your eye area.
As you know, you already have excellent lips with good vermilion show so increasing their size is a matter of adding some more volume. This could be done with fat injections as you can take advantage of a surgical opportunity since this is not a traditional office procedure. Obviously the earlobe repair can be done at the same time with any of the aforementioned procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I recently read, that a revision on a chin implant that has been inserted through an intraoral incision, can lead to distortion of the chin muscle because this muscle would be cut through twice. I don´t have a chin implant, but porex cheek implants (inserted through an intraoral incision) that need to be shaved down on the left side. Now I would like to know if an intraoral performed cheek implant surgery also involves cutting through a muscle what eventually could lead to distortion of the soft tissue if this muscle is cut through twice.Thank you in advance for your reply!
A: When it comes to surgical access in the face for the placement of implants, they must be placed down at the bone level below the periosteum. This always requires cutting through attached muscle to get to the proper placement level. But there are significant differences between the lower jaw (mandible) and the rest of the face. The lower jaw is the only bone of the face that actually moves, the rest of the facial bones are fixed. This makes for significantly different types of muscular attachments.
The mentalis muscle of the lower jaw, while having no function in its opening and closing, covers the chin bone and affects the lower lip and soft tissue movements. When it becomes detached or scarred, one can develop lower lip and chin soft tissue sagging. While good soft tissue closure will avoid this problem it is always a risk. While there is nothing wrong with secondary intraoral chin surgery, the upper attachments of the mentalis muscle are being severed and reattached twice. This does increase the potential for secondary mentalis muscle problems.
The intraoral placement of cheek implants does not cut through any muscles of jaw motion or those responsible for any soft tissue support. There are no risks, therefore, for muscle scarring that would affect any facial function or appearance. The muscle issues of intraoral chin implant surgery do not apply to intraoral cheek implant surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting chin and jaw angle implants. I would like the chin implant to be lengthened (to the most extent) and squared (to the most extent) being in the category of the latest style available on the market. The jawline height should be lengthened and widened to its proportionate maximum possibly by having a “wrap around” implant and/or separated combination of implants. Do the latest style chin implants stating the above written factors of width and length fit the “wrap around” implant or separate implants more accordantly? Thank You.
A: In answer to your questions about chin and jaw angle implants, here is the following dimensions:
Square Chin implant (Style 2 Terino), Implantech = 6.5mm anterior projection in the middle, 10mm projection on the square portion (transition corner) of the implant, 9cms long (4.5 cms back from the middle on each side)
or
RZ Extended Square Chin, Medpor = 7mm in anterior projection, 11mm projection on the square portion of the implant. Because of the central connector, the implant can be expanded and made more square which also allows for the creation of central cleft
RZ Mandibular Angle Implants, Medpor = 11mm width expansion, 10 mm vertical elongation
These three implants must be put together to create a ‘wraparound effect’ but there will be a depression between the two along the jawline because their edges are feathered where they come together. They were never made to be used to create a completely smooth wrap around jawline effect. What you may really be searching for is a custom one piece wrap-around jawline implant that can be made to almost any shape and dimension.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am thinking about getting numerous facial procedures and I have a few questions. I am wondering if getting a chin implant will stop hair growth on my chin? Whatever I have done I want a natural look, will too much facial surgery ruin this or make me look unnatural? Last question,what are some alternatives to cheek implants?
A: A chin implant will not stop beard growth on the chin. It is put in through an incision under the chin so it is very far away from the hair follicles of the chin skin.
Getting a natural result in facial surgery is based on doing whatever procedures are done in balance with the rest of the face and not overdoing any one procedure. Facial surgery, whether it is a rhinoplasty, chin implant or forehead recontouring, is making the structural change to look ike it belongs to the rest of the face.
The only alternative to cheek implants is fat injections. While I think cheek implants and their numerous styles and sizes offer more versatility for cheek changes, fat injections can definitely add volume to the cheek and submalar (below the cheek) areas. With today’s more concentrated methods of fat preparation, fat injections to the face also work better in terms of maintaining volume to the injected facial area.
Dr. Barry Eppley
Indianapolis Indiana
Q: While I don’t think that I am bad looking, I feel that my jaw line is weak and small. My receding chin greatly distracts from my features and I am hoping a jaw and chin augmentation can help balance my lower face and give me a stronger, more masculine appearance. Ideally I would like to substantially increase my chin size horizontally, to or past my lower lip when viewed in profile as well as add vertical length as my chin is rather short. I also desire to add horizontal width and volume as well as increased vertical length when viewed from the front, or in other words a more “squared” appearance. Along with my pictures, I’ve included a rough depiction of what I am trying to achieve. The altered versions are a “goal” and perhaps you can tell me if they are realistic or not. The problem is I realize extending my chin out this far requires substantially augmentation (probably around 12-15 mm) and don’t really know if my goals are realistic. I’ve been researching your website and understand you do chin osteotomy in conjunction with chin implants. Would this be a possibility? If so are there greater risks in terms of potential nerve damage and bone resorption? Also, with such an invasive surgery, are there any long term complications after say a decade or more?
A: Your own predictive computer imaging is greatly helpful and shows exactly what you want to achieve. I could not have the done the imaging any better myself. Because you desire both horizontal and vertical chin lengthening and are a very young man, I would recommend a chin osteotomy which does a better job of such combined dimensional changes. The chin can probably be advanced about 12mms or so and that should be enough to get that look. The chin can become more squared with an osteotomy by splitting the downfractured chin bone and expanding it apart to create more width. As you mentioned, an implant can also be added to the front of the chin osteotomy to create the same effect. I would have to see intraoperatively which would work the best.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley, I am interested in having a stronger structured jawline. I have been wanting this and am now prepared to have this done. I am tired of seeing a round fat face and with your expertise I think I can get the sculpted jawine that I have always desired. Here are some pics of myself and pics of jawlines that I want to look like. I think my jawline needs to be built up with a chin and jaw angle implants. Let me know what you think.
A:Thank you for sending your pictures. I have reviewed them and done some realistic computer imaging. My comments are as follows:
1) A big reality check is needed here. You can not get to or look like any of those examples. You have a completely different anatomy and skin and fat thickness of your face. While an admirable goal, it is not realistic. You can be improved and maybe end up about halfway between where you are now and those examples. All I can do is take what you have and make it more defined as much as possible.
2) A square chin implant will help the front of the jaw. Your chin needs to come forward and down to become the leading point of your face.
3) You need aggressive neck and side of the face liposuction with removal of your buccal fat pads. As much facial defatting needs to be done as possible.
4) I do not think that jaw angle implants will help you. You don’t need a wide lower jaw in the back. It is plenty wide, you need better definition of what you already have. Jaw angle implants will just make your face look fatter with no better definition.
Dr. Barry Eppley
Indianapolis Indiana
Q: Six years ago I had a mandibular implant placed as well as malar implants. I am unhappy with the end result and do not feel the result was what I requested. I think, as I did then, that a geniomandibular groove implant with extended malar implants would provide my desired results.
A: I am assuming when you say mandibular implant you are referring to a chin implant. Since you feel that a geniomandibular groove implant is better, it appears that you feel that the transition between the chin and jowl area is not a smooth or confluent one or that the jowl area needs to be more enhanced as well. Do you know what type of chin implant you have in now?
From a cheek standpoint, the desire for further malar extension suggests that either you desire more fullness out across the zygoma to the zygomatioc arch or that your desire more fullness in the submalar area suggesting more of a malar shell design. Do you know what type of malar implants you have in now?
Please send me some photographs of your face and let me know, if you can, what type of implants you have in place. A copy of your original operative note can also be very helpful as often the type of implants used are described there. Once I have this information, I can offer a more qualified response as to the best replacement facial implants for you.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in getting a chin implant to make my weaker chin look better. It seems like a fairly simple procedure but this bone resorption underneath the implant sort of scares me. Why does this happen? Is there any way to avoid this bone reorption if I get a chin implant?
A: The phenomenon of bone resorption under a chin implant is a much talked about finding for many decades. One of the reasons that it occurs is due to a pressure issue with the implant sandwiched between the soft tissues and the bone. While the implant pushes the soft tissue out, causing more visible chin projection, the soft tissues do apply a small amount of pressure or recoil back over time. Since the implant is not going to resorb because it is an inorganic synthetic material, that leaves the underlying bone to accomodate and relieve this pressure.
This pressure situation is really magnified with implants that are placed too high on the chin bone. This happens when chin implants are placed from inside the mouth and are not secured down to the lower edge of the bone. It can also happen from a submental chin incision approach but is much less common because it it easer to keep the pocket of the implant low. The observation that it does not occur with more contemporary anatomical chin implants is because the wings of the implant keep them from riding up higher, acting like lateral stabilizing bars. From either approach, if the implant ends above the basal bone of the chin (which is thick cortical bone) it rests on bone with a much thinner cortex. This is where bone resorption will be seen with chin implants. It is a function of bone position and is not an actual feature or result of the implant or its material composition per se. This bone resorption phenomenon (which is largely benign and not of any great signfiicance) can be completely avoided by proper implant position on the lower edge of the chin bone. This will also maximize the benefits of the horizontal projection that the chin implant provides, some of which is lost if it gets malpositioned higher as it slides up and back.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am very unhappy with the appearence of my jaw and cheek areas. I had ptosis surgery and forehead lift ten years ago. The eyelids are not symmetric but that’s not why I refer to you now. The profile of my face is very long and in my opinion the middle of the face is too far backwards. I’m interested in what you would propose to make my appearance more harmonic.
A: In reviewing your pictures, you do indeed have a longer vertical length to our face. This is magnified by the short or more posteriorly (backward) position of your chin point and your midface. The cheek and nasal base is very flat and your chin is significantly behind the upper lip, giving your face a more convex profile.
While you can not really shorten the vertical length of your face, you can change how it appears. By bringing forward the midface and chin through bony augmentation, you can achieve better facial balance which will make it appear ‘shorter’. This can be done with cheek and paranasal implants to the midface as well as chin augmentation through either an implant or an osteotomy. I would also recommend comsidering a rhinoplasty as well. Very frequently, long faces have an increased nasal length with a small dorsal hump. This long nose contributes to making the face look longer as well. A small change in the shape of the nose through rhinoplasty can also help change the visual effect to a shorter and more balanced face.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have had a beard for years and now I have a job that will not allow facial hair. This has made my insecurities over my chin to resurface. I am especially interested in a chin implant. After review a lot of before and afters you have seemed to me to do the best work. What is the best type of chin implant ti use?
A: Facial hair on men provides uniqueness to one’s facial appearance and is often a fashion statement. Many times, however, facial hair serves as either a distraction or camouflage technique. This is especially true for upper lip and chin concerns in men. A beard or a goutee adds at least 5 to 8mm of pseudoprojection of the chin depending upon how long the hair is allowed to grow.
When it comes to chin implants, there is no one single style or type of material used that is the best. There are over a dozen chin implant styles, which initially seems confusing, but that allows for a chin implant style that goes best with a wide variety of chin concerns and objectives. Chin implants should be looked at as more than just providing horizontal projection. The frontal view of the chin and jawline should also be taken into consideration in term of vertical height and width of the chin area. It is important to go over all chin dimensions with your plastic surgeon so the best chin implant style is chosen for you. When it comes to different materials of chin implants, there are certainly advocates for each type. I personally find the material composition of chin implants largely irrelevant and am more interested in making sure the style and the patients desires match the best.
Dr. Barry Eppley
Indianapolis Indiana
Q: Do you use screw fixation for your silicone chin implants? I have a silicone chin implant that moved upward off the inferior part of my chin. I am looking to do a revision but I want some type of screw fixation this time.
A: If a chin implant has slide too far upward for optimal chin projection, it was likely placed through an intraoral (inside the mouth) incision. This is a common problem with this approach as the dissection and the pocket created allows the implant to slide up towards the incision after surgery…unless it is secured in a low position on the chin bone by a screw. This problem does not usually arise when the incisional approach is from a skin incision under the chin as the undisturbed mentalis muscle keeps a firm ‘roof’ over the implant.
In any type of chin implant revision, where the problem is shifting from the ideal position, some method of implant fixation is needed. The easiest and most economical approach is to use a single midline screw to the bone. If side-to-side shifting is the problem (rotation), then double screw fixation may be needed.
While screw fixation of chin implants can be very helpful, it is not always needed in a primary or initial surgery. Many chin implants can be secured in the midline with a simple resorbable suture to the periosteum covering of the bone. But implants placed from inside the mouth or those that need to be kept positioned very low on the bone for optimizing vertical height need screw fixation.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dear Doctor: I’m a 47 yr. old white male in good health. A few years ago I went to India to have a jaw augmentation that was done by lipo injection which was absorbed in a short period of time. I’m looking for a better and lasting result. I would like to know if you think implants would produce a better and more permanent result?
A: The use of fat injections in the past decade has gained in popularity and effectiveness for many plastic surgery problems. The appeal of using your own tissue to create a ‘redistribution effect’ is undeniable. Since most people have some (or a lot) of fat to give, it is not surprising that the technique is being widely used. As part of that widening use effect, it is inevitable that some will use it for uses that are not biologically sound. Fat as a tissue graft has real value for soft tissue augmentation but it is ill-conceived to use it as a bone-based graft. It will fare very poorly as a replacement for chin, cheek or jaw angle implants. The reason is in understanding how implants actually work. They function as a spacer on top of the bone to provide a push to the overlying soft tissues. It takes a fair amount of sustained pressure to hold the overlying soft tissues outward. A non-resorbable synthetic implant can maintain that effect. A soft tissue graft, like fat, will resorb under that kind of pressure.
Advocates may argue that the fat graft is put into the soft tissue and not the bone and therefore has a basis for being effective. Results like you have obtained provide all the evidence you need to counter those claims. Bone-based synthetic implants are simple and effective for facial bone augmentation even if they are not your own tissue.
Dr. Barry Eppley
Indianapolis, Indiana
Q:Hi Dr Eppley i just read your”The Advantages of a Chin Osteotomy Vs a Chin Implant ” paper. I have a medium to small chin deficiency and am a male that is 41 years old. Is bone resorption something to worry about in the long time results with silicone chin implant? Thanks a lot!
A: The phenomenon of chin implant bone resorption, or the implant ‘settling into the bone’, is well known but is rarely of any clinical significance. This is a natural phenomenon when large chin implants are used. The pressure put on the underlying bone from the stretched overlying soft tissue is transmitted through the implant. Since the implant is composed of a non-resorbable synthetic material, it can not change from the overlying pressure. To accomodate the pressure, the underlying bone may resorb a little bit. This will allow the implant to settle into the bone which can be seen quite clearly in a profile x-ray.
This implant settling causes no problems other than perhaps the loss of a millimeter or two of chin projection. Since this resorptive process is so gradual, one would never know it. In most chin implants, however, this does not occur as smaller implants do not push on the chin soft tissue as much.
This potential bone change should have no bearing whatsoever on whether one chooses a chin implant or a chin osteotomy. The degree of chin shortness and the age of the patient are the most important factors in the choice one can make for chin augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Where to start? I had a chin reduction at a hospital overseas in 1992. I have never been happy with it. I have always been so self conscious that it looks odd to people when they see me from certain angles. I also felt that it was too extreme and not what I had pictured the result would look like. I also have a metalplate in my chin and too much fatty tissue in the front chin area. Is it possible to have the chin operation redone so it looks better? Or is a chin implant the answer for me?
A: Chin reductions can create unhappy results if not done properly. When you reduce bony support, you have to account for the overlying soft tissue. Reducing bone requires stripping off all of the chin pad tissues, there must be a way to satisfactorily reattach it and reduce or tighten these soft tissues. If not done, the chin bag will sag down and look like a lump of fatty tissue. Doing a chin reduction without simultaneous soft tissue management is akin to doing a breast reduction but without reducing and tightening the loose overlying skin.
There are three approaches to managing a sagging or ptotic chin pad. They include an intraoral muscle resuspension, a submental chin tuck-up, and the placement of a chin implant. Which approach is best depends on how on much the chin pad sags and one’s facial profile and appearance. If one is happy with their profile (chin not deficient), then either a muscle suspension or a submental tuck-up will work. The difference between the two depends on much tissue there is to tighten and whether one can accept a scar under the chin. If one feels that their horizontal chin position is short, then a chin implant would be preferable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m a 62 year old female interested in widening a narrow face with a chin/jaw widening implant that would also help with jaw lifting and mild jowls. Is this possible for someone my age?
A: It is unusual for a female at any age to desire a wider lower face. This is almost always a male procedure for the obvious reason of making the jaw line more prominent to create a masculinizing effect. It would be particularly rare, and the first time in my Indianapolis plastic surgery experience, to have an older woman make that request.
I suspect that the real reason for this request is to help improve the classic signs of facial aging which is that of jowling, loss of the jaw line, and neck sagging. While it is true that jaw line enhancement at the chin and even more posteriorly at the jaw angles can help fill out a lower face, I question whether the effect would be significant enough to achieve your goals.
While I will have to see your pictures, it is possible that chin and jaw widening in combination with a limited or tuck-up facelift may create a more ideal result. Widening and lifting along the jaw line is a diametric movement of soft tissues that will usually result in a better outcome than either procedure done alone.
Dr. Barry Eppley
Indianapolis, Indiana