Your Questions
Your Questions
Q: Dr. Eppley, many thanks for your email reply and I have attached some more pictures. Hope they are of the correct type – if you need better quality or closer views I can arrange that. As you can see I’ve taken photos of my profile many times and at varying body weights. The thinner I am the better my jawline looks, obviously, but I find it difficult to maintain the weight that allows this (roughly 50kg) – also I worry about when I get pregnant that I will look terrible with a big double chin.
My main concerns are that, from the front, my lower face looks chubby with jowls just to the right and left of my chin. I feel this makes me look really young but not in a good way!Like a chubby little girl! From a side(but not complete profile) view the jaw line gets hazy-looking about halfway along. In profile my chin just looks really weak which, to be honest, I wouldn’t mind so much but its the fact that this causes my neck structures to be poorly supported and therefore have a double chin. I also feel that my lower jaw is asymetrical and this can be seen from the front? Think that the left side of jaw is shorter making jowls worse on that side?
I have pushed my lower jaw out in some of the pics to get a view of what things might look like if I have a better jaw line/chin but obviously this gives me a horrible underbite and can’t walk around looking like that all day! But thought you might be interested to see the jawline I have in mind and I would hope for.
I included a pic of me at a lower weight to show you the effect of that as well….maybe I just need to knuckle down and lose the weight because currently I eat whatever I want and do NO EXERCISE at all…very bad I know!
Feel that my nose is quite fat looking at the lower portion from the front although I don’t have too much of an issue with the view in profile. Can something be done to make nose less bulbous at the end? This is definitely less of a concern for me the as it’s my chin that I really hate and think about it pretty much every day and am self conscious about it.
Many thanks.
A: Thank you for sending your pictures. What they show and you demonstrate so well is that the chin/jawline is somewhat short. Lengthening the chin by jawline distraction produces a good improvement. This manuever demonstrates to me that a sliding genioplasty would be a better treatment choice than a chin implant. Moving the chin bone forward brings with it the the underlying neck musculature and, as a result, produces a better jawline/neck appearance. One may also consider submental liposuction with the chin advancement to ensure getting the best result possible. As for the jowl asymmetry, the chin bone would be advanced symmetrically and hopefully that will make an improvement in that concern as well.
As for the nose, that would require a straightforward tip rhinoplasty to thin the cartilages and make the tip less bulbous.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have a very long chin that completely throws off the rest of my features. I live in Arizona and can’t seem to find a good MD in the California/Arizona area. I wanted to know if you could recommend someone for the procedure, or if not, suggest the feasibility of going out there for the procedure. What would be the downtime/ballpark costs for vertical reduction in the chin length? Thank you for your help.
A: Thank you for your inquiry. It sounds like you need a vertical reduction wedge chin osteotomy. As a ballpark range, the cost of a chin osteotomy is around $6500. We have many patients that come in for surgery from all over the world so this is a common experience for us. You may also feel free to send me some pictures of your face for my assessment to determine your suitability for this procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My face needs a vertical augmentation about 8mm and a horizontal one about 5mm or so. Yesterday I met a doctor in our area, he told me that with an Osteotomy surgery he can give it a nearly 2 to 3mm of vertical projection and about 3 to 4mm of horizontal projection, and above that level is impossible. He described that they cut a piece of my chin from its below, with a triangle section (kinda similar to a wedge I guess) and slide it forward and downward. I wanted to get your advice about how the surgery could be more efficient for me and how I can reach my desirable face.
A: You are referring to a sliding genioplasty procedure. The dimensional movements to which you have been told are far below what is possible. While I don’t know what your chin looks like, I would see no reason why you couldn’t have an 8mm vertical elongation and a 5 to 6mms horizontal advancement. Such movements are possible because of the use of specially designed chin plates that can be adjusted for a wide variety of chin movements to hold the bone in the desired position. I have no idea why you have been given those small chin movements as being what is possible. But to say that 8mm of length and 5 to 6mms of horizontal increase are impossible is not accurate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a couple of questions about doing a genioplasty to reduce the length of my chin. First of all a vertical shortening of the chin would require an intra-oral approach, correct? Or could it be done via submental approach? Where would you rank this procedure in terms of potential risks and permanent negative outcomes? Als, how is it with European patients? Have you had people fly over from Europe before? And if so, how is the process concerning consultation, surgery and post-surgery follow-up? Is it possible to fly over for a consultation followed by surgery on the same, or one of the next few days? Or is an online consultation enough for you to assess the patient? Maybe an x-ray exam. is required for a procedure like the one I'm heavily contemplating?
A: In answer to your questions:
1) A vertical chin reduction osteotomy needs to be performed intraorally. The only risk of this procedure, besides have we achieved the aesthetic goal, is some temporary lip and chin numbness from the mental nerve which will be exposed in doing the procedure. While some permanent sensory loss is possible, that is not something that patients have reported to me.
2) We have many far away patients from all over the world so we are very familiar with how to manage them. As we are now doing, all of the details of diagnosis and treatment planning can be done by e-mail. My assistant will arrange for a Skype consultation as it is always good to talk, if possible, face-to-face from afar although this is not absolutely necessary. Surgery is arranged and then the patient arrives the day before and then we can meet in person at that time. Surgery is performed the next day and you should be able to return home within 48 hours. There are no sutures to remove and no real physical restrictions after surgery. Follow-up is done just as we are doing now by e-mail. From a chin osteotomy, expect some significant swelling for a few weeks after surgery but usually no bruising.
3) The only preoperative test that I would need is a lateral cephalometric x-ray so I can take measurements and see how much chin bone can be safely removed/reduced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m unhappy with my face. I think the horizontal projection is very poor and the jawline is weak. Just starting to look into options and I would be happy to hear any ideas you have. My first thought was that chin implants might be helpful. I’m hoping to create a face that Asian and white women will find very attractive and projects warmth while also commanding respect in a business setting. I have attached a profile picture for your thoughts.
A: I am not sure what Asian or Caucasian women would necessarily find attractive or what facial appearance projects warmth while commanding respect in a business setting. But in looking at your side view pictures, I would agree that your chin is weak and out of proportion to the rest of your face. Having a more proportionate chin would give your face better balance and is what I think you would give you an improved facial appearance that may be considered more attractive as well as casting an image of greater masculinity. I have done some imaging on your side picture to see if you agree. The chin augmentation, which could be done by either implant or a sliding genioplasty, would benefit by concomitant neck liposuction as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my face is very unbalanced as my chin is very short. This also makes my neck look fat even though I am at a good body weight. I have attached some pictures for you to tell me what you can do for my really short chin. It looks like the lower part of my face is just missing.
A: Here is a side view prediction based on the combination of a chin bony advancement (sliding genioplasty) combined with an implant. Your horizontal chin deficiency exceeds 15mms which puts you well beyond what any conventional chin implant can do. A chin osteotomy will advance you up to 12mms, which is better, but also not ideal. Therefore, in cases like yours I will put an implant in front of the advanced chin bone as well that will add another 5mms to the projection. The addition of the implant also has the advantage of its extended lateral wings which will fill out the sides, making the chin a little more square. That is an advantage for a male who benefits by a more square chin anyway. In addition, your thicker neck tissues would simultaneously benefit by liposuction under the advanced chin area to try and thin that out a little but.
The combination of a chin osteotomy and implant combined with neck liposuction can make some significant changes as the imaging suggests. This type of ‘extreme chin augmentation’ is necessary to get the best result in larger male chin deficiences like yours.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in neck liposuction, revision rhinoplasty, and cheek augmentation. I want to get rid of neck fat, define my jaw and neck line, straighten nose-one side of nose is bigger, and add volume in mid- and lower cheeks and under eyes. I have attached pictures for your review and assessment.
A: In looking at your pictures and your areas of interest, I can make the following comments/recommendations:
1) You jawline is ill-defined because your chin is both horizontally and vertically short. This makes your lower face look very deficient and creates a lack of any jawline definition. What you would ideally benefit from is a vertical-lengthening chin osteotomy which adds lower facial height and creates a more obvious jawline. This will also improve the appearance of a fuller/fatter neck although some submental liposuction done with the chin procedure would complement that improvement.
2) Your nose shows numerous secondary rhinoplasty issues. I do not have the benefit of knowing what you looked like before but I see issues relating to lack of upper dorsal height, tip asymmetry/thickness, nostril asymmetry and a deviated columella.
3) The need for volume in your cheeks and lower eyes is a bit perplexing to me. I see no benefit to lower eyelid volume augmentation. Perhaps with the chin lengthening, more volume in the lower cheeks (submalar implants) may be aesthetically beneficial to you. I have left those areas unimaged so you can see the other more important areas of facial change first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had two procedures done 20 yrs ago. I don’t know the name of the procedure but I had a large amount of gums showing when I used to smile. They cut my upper jaw and raised it up, so I didn’t have the “gummy” smile. I then had my chin moved forward 11mm. I believe I have some underlying scar tissue from my upper jaw surgery underneath my cheeks. When I smile, my cheeks stand out and my face looks disproportionate. Can this be improved? Also my chin is still somewhat horizontally short. Can it be moved further forward again?
A: Your original surgery was a LeFort I or maxillary impaction to shorten the upper jaw and a sliding genioplasty to move the chin forward. The fullness that you have/feel in your cheeks is not really scar tissue per se. It is due to the release of the facial tissues made during the vestibular incision for your maxillary osteotomy. This causes some of the tissues and their muscular attachments to retract out to the sides into the cheeks, creating increased cheek fullness and what I call a ‘LeFort Look’ which is classic. This has long been recognized and is why at the completion of the maxillary bone surgery the vestibular incision is closed in a V-Y fashion to restore the midfacial tissues position. At this point in time after surgery, these tissues can not be respositioned. It may be possible to remove some of the buccal fat pad to reduce this fullness.
From a chin standpoint, osseous genioplasties or chin osteotomes can be repeated. The only complicating factor could be the fixation hardware used to secure the bone from the original surgery. Whether it was wires or plates and screws, these devices often get covered by bone healing and can be difficult to remove, hence blocking a good bone cut. Depending upon the indwelling hardware, it may be preferable to consider an implant rather than a repeat osteotomy. Whether chin implant or osteotomy should now be done can be determined by a simple x-ray, like a panorex, so the type of hardware in place can be seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a long chin that goes straight down as apposed to sticking out a little bit. I would like to have my chin shaved down so it’s shorter and somehow have it stick out instead of going straight down. Another reason this problem is so severe is because I have an extreme-overjet, but I’m going to a dentist to try to find a solution to that problem.
A: Based on your description of your aesthetic chin concerns and desires, what you actually need is a chin osteotomy (bony genioplasty) not a chin bony burring. A chin osteotomy removes 5 to 7mm of vertical bony height AND can move the chin forward whatever number of millimeters is desired. This procedure gives you both a vertical chin reduction and horizontal chin projection. This is the only chin procedure that can make those changes, which sounds exactly like what you are looking for. If you send me a front and side picture, I can do some computer imaging to show you what those chin changes would be like.
In regards to your occlusal overjet, that dental bite problem may be a contributing factor to your horizontal chin shortness but does not affect the chin being too long. In looking at the one picture you have sent, I do not see any evidence that whatever overjet you have would represent a severe mandibular deficiency. You should have an orthodontic work-up but I do not think it likely that there is major orthognathic surgery in your future.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, there is an overall lack of definition to my face (flat cheeks and very prominent and long chin) which you will notice here. It’s my belief that with some cheek contouring and possibly jaw as well, I may look as beautiful as I feel. When I smile and when the lighting is even I have a much more appealing appearance as it seems to round out my face if you know what I mean. When I’m not smiling and when the light is harsh (as it usually is unless one is in a photography studi0 and manipulating light!) I feel like my face is a sliver- very long with nothing to break it up or draw the eye up. I look forward to hearing what you think!
A: In looking carefully at your facial features, there are three areas that could be altered to help make the transition from a long flatter face to one with better proportion and angularity. As you have mentioned, your cheeks/infraorbital areas are flat, your chin is long and slightly retruded and your nose is slightly prominent and a little deviated. Changing all three would make the greatest change but I just want to focus on your cheeks and chin for now. Cheek implants with anterolateral augmentation and a chin osteotomy that vertically shortens the chin and brings it forward is the best way to help vertically shorten your face and ‘pull’ it outward. I have demonstrated that on the attached imaging pictures in the side and front views. I think a reductive rhinoplasty would also be very helpful to shorten and deproject the nose, which would make the midface look more full, but the pictures you have sent are not of good enough quality to do the rhinoplasty imaging justice. But these initial images will give you some good material to think about.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like a straighter more refined nose and a stronger jawline. This may require a chin augmentation but I am not sure what I really need. I just want to look more refreshed and have a more attractive face. I have attached some pictures for you to see and give me your recommendations.
A: Thank you for your inquiry and sending your pictures. I have taken a look at them and can give you the following thoughts.
Your chin deficiency is as much a vertical one as it is a horizontal one. This can not be treated by a traditional chin implant as they can only provide increased horizontal projection. Vertical increase is very important in your chin augmentation. Either a custom chin implant needs to be fabricated or a chin osteotomy needs to be done. Either approach can be successful and I have done many both ways. There are advantages and disadvantages to either approach and they can be discussed in detail further by phone or by Skype.
Your nose shows a lack of tip projection and definition. The nasal tip is rounded and more ball-like. I do not see the lack of straightness in your nose that you have indicated in your inquiry. This can be improved by an open rhinoplasty with the use of a columellar strut graft alar rim grafts and tip reshaping.
I have attached some before and after computer imaging to show the potential changes of the nose and chin based on these approaches.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, here is a some photos of my face from both side angles and front on. Any suggestions you have on improving my chin / side profile will be appreciated. I’ve already have a very low fat content in my body, but my jawline is still ill-defined. I’ve been considering a sliding genioplasty to move my chin forward. I play a lot of contact sports (boxing, wrestling, soccer), so I imagine a chin implant isn’t a great option as it could shift. Let me know what you think. Thanks a lot for your time.
A: Thank you for sending your pictures. It is a little hard to see precisely your chin position due to the amount of facial hair, but I have some projected imaging based on much chin advancement I think you would need. I would estimate from 7 to 9mms forward increase. In addition, I have opened up the osteotomy to give some vertical chin lengthening as well of about 3mms. You are correct in assuming that moving your own chin bone long term is better than using an implant if you do participate in a lot of contact sports. Chin implants can be used and screwed into place so shifting with trauma is not a big concern. But it only makes sense to not unnecessarily expose a protruding chin implant to trauma. Your bone is much better designed to withstand that than an implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, first of all I want to say that your site is full of information and i have learned a lot of things. I want to do an osteotomy/genioplasty on my chin to achieve facial balance cause I have a receding chin. I also want to do this surgery to shorten and make my lower lip thinner. Will this surgery tighten the lip and chin musculature and will it cause my chin to look thinner? I am looking forward to hearing from you.
A: In most cases of an osteoplastic genioplasty where the chin is advanced, it will make the width of the chin thinner. This is because a chin osteotomy is like advancing the front part of an upside U forward. It is elongating the U and makes it more narrow. Whether that effect is significant or not depends on how much advancement is being done. But anything over 5 to 7mms, the thinning effect will be seen. It does not usually make the lower lip any thinner however.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin advancement done several months ago due to my severe lower jaw deficiency. I just want to ask a question. I definitely feel there has been an improvement since having the chin moved, but I was wondering what your opinion is on whether moving my jaw itself would ever be possible in my case because I still feel that my lower jaw deficiency is problematic. I would assume as an oral surgeon it is a procedure you are familiar with. I have had a lot of dental work done which definitely complicates things unfortunately, but the appearance of my lower jaw is still something that bothers me. I am currently 24 years old and have been bothered by it tremendously for years now. I do realize that jaw surgery is very costly unfortunately, but the financial realities aside, I just wanted to hear your opinion about whether it even is a possibility given the dental work I have had done in your opinion. I definitely regret not taking better care of my teeth and would do it all over again if I could because of how much of a toll this problem has taken on me.
A: In looking at your x-rays, you do have an overall lower jaw deficiency with a Class II malocclusion. Your indwelling dental work aside, the question of whether you could ultimately have a sagittal split mandibular advancement first requires an orthodontic opinion. Such orthognathic surgery requires a period of orthodontic preparation and after surgery orthodontic fine tuning. While I suspect you are an orthodontic candidate, how much time that would require and the associated costs would have to be answered by an orthodontic evaluation. This orthodontic process is the rate-limiting step for any patient considering orthognathic surgery as the jaw(s) can not be moved without it in place and having the teeth realigned for such surgery. As an cosmetic camouflage alternative, that is why you have a chin osteotomy initially.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want symmetry in my face after a few events that changed it. I want to breathe better. I want my nose to be as it was before trauma, might need cartilage graft on left side. I want my jaw to be more angular and symmetrical with osteotomy after having broken jaw. I want my left eye to look like my right eye, cause could be previous rhinoplasty or trauma involving prolonged eye poke. Here are some pictures of me.
A: Thank you for your inquiry and sending your pictures. I can clearly see your concerns in all three areas. In looking at your pictures, I can give you the following suggestions for these areas as follows:
1) Nose – a septorhinoplasty is needed to straighten the septum, harvest a septal cartilage graft, decrease the size of the inferior turbinates, and reconstruct the external nose with a right middle vault spreader graft. Your external nose may benefit by other changes but that is as much as I can say based on these two pictures.
2) Jaw – To correct your asymmetric jaw, I would not do a traditional jaw osteotomy. This requires preparatory orthodontics and a whole change in your bite. The asymmetry could be better camouflaged with a sliding chin osteotomy to correct the midline of the chin and jaw angle implants to create a more angular and defined look.
3) Eye – Your lower positioned eye needs to have the orbital floor built up with an implant and possibly both the orbital floor and the orbital rim needs to be augmented. This would raise the eye up and help bring it more forward as well.
Your pictures are not really adequate to do good computer imaging but I have attached the best I could do with the one picture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi. My jaw points down and my chin is very weak. I would like my jaw to appear more square shaped. I don’t think this is a problem with the growth of my jaw as my bite is excellent and I wouldn’t want to mess with it anyway. I considered a chin implant but that seem to just make my jaw longer as it would sit on a backward angled segment of bone. Also, my nose has a high bridge, so I am wondering if rhinoplasty might off set the look of the jaw. Right now, my jaw line and the bridge of my nose are almost parallel lines. What is your suggestions?
A: In looking at your pictures, your mandibular plane angle does parallel the dorsal line of your nose. This is not a nose problem as its shape and size looks good. A rhinoplasty you most certainly do not need. You need to reorient the plane of your mandible. This would be best done by a combined chin osteotomy and jaw angle implants. The chin osteotomy would bring the chin forward but would also bring it upward due to the angle of the osteotomy cut. This will actually shorten the vertical length of the face. The jaw angle implants will bring down or lengthen the ramus of the mandible of posterior length of the face. These two procedures together will create a counter clockwise rotation of the mandibular plane angle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering a chin osteotomy as opposed to a chin implant for my weak chin. What I am most concerned about, however, is the complications that may be involved (numbness around the area and using titanium plates/screws inside my bod). As I have decided not to correct my overbite, would you still recommend that a sliding genioplasty would be a good option for me? Thank you very much.
A: In my opinion, the sliding genioplasty is and has always been your best solution. It solves all your chin issues at the same time. I would not concern about titanium being implant and in your body for the rest of your life. Titanium is the most biocompatible metal that is known in medicine and will be completely overgrown with bone anyway. I have never had to remove titanium plates and screws from a chin nor have I ever seen it to be a problem. This is the best place for such metal materials in the face because it is has a thick bone and soft tissue cover and is not exposed to the stresses of mastication. While there is always the risk of some feeling loss from chin osteotomies, my experience is that it is very low. The key is to do the osteotomy at least 5mms below the mental foramen if not lower to avoid any risk of permanent loss of sensation to the lip and chin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am primarily concerned with the lower third of my face. I think my chin is too long and pointy which contributes to the long, thin face look. Do you think a chin reduction combined with jaw implants or a pre jowls chin implant would do the trick? If so, do you perfom such procedures? Do you have any other suggestions as to how I could improve my facial features? Please do not be afraid to hurt my feelings!
A:Thank you for sending your pictures. Your long thin face is partly the result of a long sweeping jawline with a modestly steep mandibular plane angle. This makes for a lower face that appears vertically long. This is magnified by the observation that your midface (cheek and paranasal areas) is relatively flat/recessed. That combination makes for what you see,, a face that has a greater vertical component than horizontal projection and width.
To address this concern, I would recommend a chin osteotomy which, based on the angle of the cut, allows the chin to become vertically shorter as it comes forward. You need both a mild amount of horizontal increase with an equal amount of vertical reduction. Only an osteotomy can make this bony chin movement possible. In addition,. I would place jaw angle implants that both widen and vertically drop the jaw angles downward. Between the chin and the jaw angle changes, the lower third of your face would become shorter and wider. That will help counter the long thin face look. I have attached some predictive imaging to illustrate these changes.
The other change that would be helpful is cheek augmentation. That would bring the midface more forward, again a manuever that counters the vertical and thin (horizontally deficient) facial appearance. I have attached an image that shows where this cheek augmentation would be. Your pictures are not of a good enough quality to really show what cheek augmentation can do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to have corrective jaw surgery for my long face. I don’t have an under/overbite but I do have longer face which I would like to be shortened. What are the options available for doing this? I have attached a picture for your assessment.
A: There are two fundamental approaches to aesthetically shortening the long face. The first is a vertical chin reduction osteotomy in which only the chin length is reduced. (shortening of the lower third of the face) I have attached an imaging picture of what that may look like on you. This would be the simplest technique but it only deals with one area of vertical excess, the chin. A true long face is most people involves the entire face. The second approach, which is usually combined with vertical chin reduction, is a maxillary impaction or shortening. This requires that the patient has a vertical maxillary excess to start with as reflected in having a lot of tooth exposure and/or a gummy smile and lip incompetence. This shortens the middle part of the face which when combined with vertical chin reduction gives the maximal shortening effect. This is a more extensive approach requiring a LeFort I osteotomy and, again, requires that the patient have vertical maxillary excess. Your pictures suggests that you have that to some degree based on your tooth show/lip incompetence at rest. This is a harder area to image given that it is in the middle part of the face.
Which approach is best for any patient depends on how much vertical shortening they need and what one is prepared to got through to get what degree of shortening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty four years ago. Everything went well and I like the result. My surgeon told me that he could remove the titanium plates and the screws but it wouldn’t be a problem if they stay inside me for the rest of my life. So I decided to let them stay inside of my chin. Last week I meet another surgeon who said that titanium plates and screws should be removed in younger patients. On ‘House MD’ it has been shown that titanium plates can severely burn soft tissue and skin when an MRI is needed. Is this true? Should my titanium plates be removed because they can lead to bone resorption or other problems in the future?
A: The simple answer to your question is that none of what you have heard or been told is true. Titanium is the most biocompatible metal in the body which is why it is so commonly used. In facial plates and screws it is a nearly pure metal to which bone will bond directly (and often grow over) and it is non-ferromagnetic so it is not affected by the powerful magnetic influence of an MRI. There is no reason whatsoever, therefore, to remove your chin osteotomy plates and screws. Of all the places on the face where rigid fixation is used, the chin is the one area where I have never seen any long-problems such as loosening, irritation, or interference with function. Removing them may be a good exercise for the surgeon but is of no benefit to you at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, one year ago I underwent surgery for a medium chin implant and neck liposuction. Though I was initially pleased with the result due to the way the swelling made my chin look, after the swelling had subsided I was very disappointed with the outcome. I feel that my chin and jaw line are vertically short and that my chin is still a little bit horizontally short. Additionally, my jaw line lacks solidity and I think that my chin could stand to be a little wider/fuller. I have attached two photos of what my face currently looks like.
I would like to add roughly a 1/2 inch to my chin/jaw line vertically, as well as 3-5 mm horizontally (from where the current implant ends). I would like my jaw to angle down to my chin, so that the chin is lower than the rest of the jaw. As I previously mentioned, I would also like my chin to be a little bit wider and to add solidity to my jaw line as it gains fat easily.
In order to obtain the results that I desire and keep them long-term, what would be the best procedure for me? The three that I have been looking at are a sliding genioplasty, a geniomandibular implant with Gore-Tex strips or a custom jaw implant. Money is a little bit tight for me, so I’m hoping to avoid the custom jaw implant.
I appreciate your help and eagerly await your response,
A: I have taken a careful look at your photos and your desired aesthetic chin changes. While a custom implant is one method to achieve those changes, it is not the only way as you have pointed out and the cost of it eliminates it from consideration by your own admission.
Between a chin osteotomy and geniomandibular implants, each has its own advantages and disadvantages. A chin osteotomy (keeping the chin implant in front of it) would easily create 10mms of vertical lengthening, about 5mms of additional horizontal advancement and could be sectioned to create 5mms of horizontal expansion as well. It is done from the inside of the mouth and would actually be my preference in your case even over a custom chin implant. Geniomandibular groove implants could also provide up to 10mms of vertical lengthening and 5 to 7mms of horizontal widening as the implants can be placed with separation between the two sides. The problem with these implants is that you would only get about 2 to 3mms of additional horizontal advancement and your existing chin implant would have to be placed on top and in front of it to keep and enhance the horizontal projection that you already have. That is not a big problem, just that you have two implants stacked together. This procedure would need to be done from a submental skin incision from below the chin with a resultant scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interesting in what you refer to as an extreme chin augmentation (osteotomy and an implant). I have a short lower jaw, but unfortunately have been told I’m not a candidate for orthognathic surgery due to the position and condition of my teeth. To help correct this problem, I have had a chin implant placed but the results do not satisfy me as it is not big enough. I am attaching a copy of my ceph x-ray. I do not have a profile picture at this time, but it is pretty clear where my chin is from this x-ray. Can you please comment on having this surgery? I have seen a lot of your before/after pictures on other sites for chin augmentation and am very impressed with your work and the knowledge you seem to have from the questions you answer on your site.
A: Thank you for your inquiry and sending your ceph x-ray. You do an underlying significant lower jaw deficiency as seen on your film. Your current indwelling chin implant provides only 7mms horizontal projection and is positioned just slightly high on the bone. Your true chin deficiency is more in the range of 16 to 18mms deficient. You therefore already have half of an extreme chin augmentation with the existing implant in place. You now need a chin osteotomy done just above your existing implant to advance the bone (carrying the implant) forward about 10 to 12mms with a vertical opening of 2 to 3mms. This will create the most ideal chin projection for you. So doing the previous chin implant was not a wasted procedure. You would have needed it anyway as the bone can only be brought forward so far. i have done some computer imaging and predictive tracings on the ceph x-ray that you have sent me.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I think that I need my chin lengthened downward. I have a very deep overbite. I have attached a variety of photos as I wanted to show you my face shape when my teeth are closed together (I have a deep overbite) and when they are not. Most of my teeth are bridges and crowns and I have recently been advised to have all of them removed and implants put in place and that would help my overbite and give me a lovely smile. I don’t know if this would help as it is unclear to me if my overbite is dental or skeletal. I am under the assumption that my problem is skeletal as I thought my overbite would be addressed when all my teeth were replaced around 6 years ago but this wasn’t the case. Unfortunately it isn’t really a financially viable option for me to now have all my teeth removed and replaced. I also sought advice a couple of years ago and although I was only 45 at the time, I was advised to have a facelift and nose job to improve my jowling and small chin. I did so but I don’t feel the real problem has been solved. I would appreciate your professional advice on how an improvement can be made.
A: Thank you for sending your pictures. I can see that you have a 100% overbite, which means your lower jaw is over rotated on closure thus shortening the entire lower face. This is a skeletal problem that is manifest by the presence of the occlusal discrepancy. But because of the arc of rotation, the vertical shortening is greatest anteriorly at the chin. As a general rule, the amount of vertical shortening in a 100% overbite can be calculated at the vertical height of the incisor teeth. (crown length) That would be somewhere between 10 and 15mms in most patients. So you are absolutely correct in desiring a vertical chin lengthening osteotomy. That would provide the greatest benefit in terms of improving lower facial height and overall facial balance. I have done some computer imaging which shows the predicted outcomes from that procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin osteotomy several years ago but still feel my chin is short. Do you think another chin osteotomy can be done. I do not want an implant for more chin if I can avoid it. I have attached an x-ray so you can see what my chin looks like now.
A: Your x-ray shows that you had a sliding genioplasty fixed together with cerclage wires. What this means and shows is that the back cortex of the chin segment has been brought forward enough to be attached to the front cortex of the mandible. This means that the chin segment has been brought forward as far as it can go. This is an older genioplasty technique that dates back to a time when only wires were available for facial bone fixation. Since the wires can only attach to the cortices of the bone, the chin is brought forward whatever distance the back end of the chin and the front edge of the upper bone will allow as they match together. In today’s genioplasty bone fixation techniques, plates are used that move and hold the chin together at any desired distance horizontally as well as vertically.
In theory, you should not be able to get any more advancement out of the chin segment once a ‘maximal’ bony genioplasty has been performed. But there is one thing that is a bit unusual in the way your chin osteotomy was performed. The x-ray shows that it was cut at a very low horizontal level. This has left a lot of bone height between the lower end of your incisor teeth and the top edge of the bony cut. This suggests that a new osteotomy could be done above the old one, bringing more of the chin forward. This would create a ‘stairstep’ chin osteotomy approach which I have done at the same time but never as a staged procedure which is actually safer. So I do think a repeat chin osteotomy is possible to gain more chin projection. In stairstep chin osteotomies, I do recommend the use of hydroxyapatite granules or demineralized bone to fill in the steps at the end of the procedure for maximal bony healing.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, I need to have my chin brought forward as it is very weak. I know that the bone hs to be moved given how short it is. I want to have this surgery but I have a lot of questions. I am hoping you can answer them for me. Will I need to put braces or get some teeth removed to do this? How long will I have to stay in the hospital and how long will it take me to recover completely? In case I meet with an accident in the future and hit the chin, what would be the consequences? In case I meet with an accident in just a few weeks/months after the surgery and hit the chin, what would be the consequences? What are the risks of this surgery? In case the results are not what I desire, what kind of measures do you use to fix it? Any long term side effects? How painful will it be, and for how long can the pain last. Are there any breathing problems? How different is this from a complete jaw surgery? Are there any visible scars after the surgery? If yes, where exactly on the face? Thank you in advance for taking your time to answer my many questions.
A: If one is having the whole jaw advanced, braces are needed. I have not seen your bite nor do I know if you have any interest in changing it. If so, then presurgical orthodontics are needed. However, I am assuming that this is a chin osteotomy advancement and not the whole jaw so the answer would be that no braces are needed. All the remaining answers are based on a chin osteotomy procedure. This is an outpatient procedure and is done in a surgery center not a hospital. The chin bone will heal normally and will be no different than your normal chin bone is now once full healed. The chin would not move after the surgery since plates and screws are holding it together as it heals. The biggest risk of surgery is some temporary numbness of the lip and chin. If the look is not adequate or the chin not advanced far enough, the bone can always be readjusted or an implant placed to augment it further. I have never seen this so it is unlikely. There is no risk of breathing problems from chin surgery. Most patients report that the chin area is sore and mildly uncomforatble but not severe pain. In a chin osteotomy, only the deficient chin bone is moved and does not involve movement of the rest of the jaw and the teeth. Everything is done inside the mouth. There are no external scars.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello, my problem is that I have a lower anterior face height deficiency. Because of that my total face looks very small. First I didn’t know what the problem was. After examining my face very well I came to see that the lower anterior face height is very small. I have a very little chin and small jawline. I have read your article entitled ‘Case Study: Vertical Jawline Lengthening for a Short Lower Face’, and I think I have the same problem as this girl that is mentioned in the article but a bit worse than that. I have attached some pictures of my face so that you can take a closer look. When I look at the photos I think my lower anterior face height should be longer. Can I do this with a chin and a jaw implant or some kind of other implants? Because I’m not sure what kind of implants the girl in the article had. I think I have the same problem as her but more extreme. I would like to know your professional opinion. I went to a local plastic surgeon but they didn’t understand what I mean or maybe they just don’t have the techniques. They kept saying my chin had the right position. (apart from that my chin). Because my lower anterior height is small my forehead looks a bit big. But it is a normal size forehead, it’s just compared to the lower face it looks big. So I think my face needs to be lengthened vertically and a bit horizontal at the jaw (because when it is only vertically lengthened my face will look long, because I don’t have a wide face). I hope you see what I’m trying to say because I know something is not right.
A: I can see perfectly what your facial concerns are and you have stated them quite accurately. Your lower facial height is proportionately short compared to the upper two-thirds of your face. Your chin needs to be vertically lengthened by 7mms and horizontally advanced 5mms. That can not be done with an implant but requires an osteotomy. There is where the chin bone (not the main jaw bone) is cut and moved down and forward. It is held into its new position by a small plate and screws as it heals. This is done from inside your mouth through a small incision in the vestibule below your front teeth. This is a common chin surgery that I regularly perform which is highly successful at improving your lower facial lengthening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want to make numerous changes to my chin as I think it will make my face look better. I am looking to decrease the horizontal dimension of my chin as well as increase the vertical dimension. I think this will create a more angular jawline as my lower face is very rounded. My chin feels like it pushing my bottom lip upwards so I wanted the lower lip to be brought down slightly, would this be at all a possible? I would also be wanting a rhinoplasty, however at the moment, I will be focusing on the chin. Would these chin changes be best done with an implant or an osteotomy? I really hope you can help Dr. Eppley. Thank you for time.
A: That type of chin change can only be done by an osteotomy. With the chin pushing up on the lower lip, this suggests that it is too vertically short. A chin osteotomy can easily increase its vertical length by making an opening wedge that is held apart by a special chin plate and four screws. Lengthening the bony chin will always make it look thinner, but its bony width can also be narrowed by a midline ostectomy of the downfractured segment at the same time.
As the chin is lengthened, it can create a slight lower lip lowering effect as the mentalis muscle is also lengthened. As the upper attachment of the mentalis muscle does extend to just below the lower lip, its lengthening as it is carried down with the bone should make the lower lip less pushed up.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I want a stronger chin and jawline. I currently have a 7 mm winged chin implant in now (with rhinoplasty last year), but feel the asymmetry lies more in the vertical dimension. I also feel that my mandible does not have enough lateral dimension or width. It seems that my lower face is somewhat deficient in multiple planes and I’m unsure which would be better for me, a chin osteotomy with vertical and horizontal augmentation combined with a widening of chin, or a custom wrap around implant. It might be helpful to see the predicted outcomes of both. And, of course, I would love to hear what you think might be best based on the picturesI have attached. Any other suggestions you might have would be appreciated also.
A: I think factoring in all considerations and looking at some imaging predictions, I would opt for the chin osteotomy. The recovery time is actually shorter with the implant but the photographic projections shows what an osteotomy can do and that seems to be the bulk of where the change needs to be to get your face more balanced. Given your 7mm implant that is already in place, your osteotomy needs to come forward 11mms and down at least 7mms. This will require plate fixation and hydroxyapatite block grafts.
Also I have noted that you could benefit from nostril widening. That parft seems to have been overlooked in your original rhinoplasty as well as some additional tip refinement. I would also consider adding in buccal fat removal for submalar narrowing and this would add nothing to the recovery time.
Dr. Barry Eppley
Indianapolis Indiana