Your Questions
Your Questions
Q: I have recently consulted with a maxillofacial surgeon who has recommended performing a chin osteotomy procedure. He intends to remove a 3mm wedge (for vertical reduction) as well as a 3mm advancement, with the osteotomy performed at a slight upward angle. I seem to have the unique situation of anterior mandibular vertical excess with a very flat labiomental fold (which would be enhanced by the advancement) What are your thoughts on the success of this procedure?
A: Without looking at photos and x-rays, it would be impossible for me to comment on whether this is a good procedure for your concerns or not. That is a technically sound chin osteotomy procedur and is very straightforward to do. The only question I would raise about it is that these bony movements (3mms) are fairly small. Such small movements are unlikely to make much of an external visible change, albeit a very modest one. To take down the chin bone by osteotomy for this amount of bony movement seems like a ‘solution that is bigger than the problem’. For a horizontal advancement of 3mms, an implant would be far less invasive. For a vertical reduction of 3mms, there is no other solution than osteotomy and bone removal. This makes it a difficult decision in my mind as to whether the problem justifies this degree of surgical effort. I would look at your chin concerns carefully and would reconsider carefully the potential benefits and risks of this type of chin surgery.
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: I am interested in making my weak jaw look much stronger. My chin is very short and my lower face looks too small compared to the rest iof my face. The more research I do , the more I think I might have micrognathia (abnormally small jaw), and I don’t know that jaw implants would not be enough to make me look normal. I would have to make my jaw bigger through other means like surgery or appliances. All the maxillofacial surgeons I have talked to deny giving me surgery because they claim they only do surgeries for people who have bad bites/deformities etc. and not for people born with a genetically smaller face/jaw. My bite is normal and I have had orthodontics in the past. This is getting me really sad because I feel I have run out of solutions. I need to expand my lower jaw significantly before I get implants. What is a surgical or non surgical way to make the jaw significantly bigger? I am thinking about lower jaw expanders and then add your implants. Or possibly bilateral sagittal split osteotomies (BSSRO) to advance the jaw and then add your implants on top of them.
A: There is no mystery here or need to do research to figure out what you have. You have a short lower jaw…period. A short lower jaw = micrognathia. Your entire lower jaw can NOT be moved forward by orthognathic surgery or a BSSRO. You have to have a bad bite or Class II malocclusion to do so. Moving your lower jaw moves your lower teeth with it. You can do a BSSRO if you want to have a bite where you lower teeth sit in front of your upper teeth and they don’t fit or come together at all. Get the idea of ever moving your lower jaw out of your mind…..unless you want to spend 3 years in orthodontics to reverse your bite and prepare it for surgery by giving you a bad bite. Your lower jaw is so significantly short (> 15mms) that even the biggest chin implant will not provide ideal correction. This is why you need a CHIN OSTEOTOMY, most likely with a chin implant placed in front of the moved chin bone. There is no such thing as a ‘lower jaw expander’ nor are there any non-surgical treatment methods.Your only lower jaw options are jaw angle implants for the back and a chin osteotomy/implants for the front. Focus your attention on these considerations, rather than searching for something that doesn’t exist or can not be done on you. These are your only viable solutions
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a question about jumping genioplasty. I am curious, if you have had previous chin surgery with indwelling plates and screws as well as possible internal scarring of the muscle that causes creases in your chin when you smile, can you still undertake a jumping genioplasty? Or would the scar tissue and plates and screws from the previous ostetomy prevent this? I understand this makes surgery more difficult to carry out. I was just wondering if it is still possible.
A: While you are correct in that it is more difficult, it is not impossible and sometimes is fairly uncomplicated. The only limiting factor is the plates and screws used from the first osteotomy and how easy they are to remove. The typical osteoplastic genioplasty, if the chin has been advanced, is a step titanium plate with 4 or 6 screws. As long as bone had not completely grown over these metal devices, they are often fairly easy to unscrew and pry out the step plate. But if bone has completely covered these devices, their removal can be very difficult and destructive. Fortunately, complete bony healing over the plate and screws is not common. Once the devices are removed, the osteotomy is straight forward and the prior chin surgery actually makes it easier to complete a secondary bone cut.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr Eppley, I am an Asian female. I have had an advancement chin osteotomy, 4mm forward and 2mm downward. But the result makes me have a long flat face with wider chin. As it’s not just the tip of the chin move forward but also the wide chin so it’s not good. I am guessing that the chin bone should be trimmed and I was wondering if it can be done in 2 to 3 weeks after the chin osteotomy has been done? It seems the swallow is not yet gone, is it good for immediate surgery again? Also I will do a facelift with fat transfer with other surgeon. I was wondering if I should wait and to have the chin bone trimming and facelift done at the same time, rather than do the bone trimming now? If I can’t do them together, how long should I wait before each of the steps? I look forward to hearing from you very soon.
A: Based on your description, it sounds like your chin osteotomy was just done. Your chin bone movement was very small and I doubt that amount of bone movement would make your chin ultimately look wider. I think what you are seeing is swelling, particularly if it has just been done in the past few weeks. You can not really judge the dimensional changes after a chin osteotomy, particularly width, for several months. I would advise waiting 3 months and then see what you think. There is no reason you can not do some chin reshaping if needed with a facelift and fat transfer later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a 19 y/o male with a receded lower jaw along with a very small chin. I am very unhappy with my profile and unable to afford corrective jaw surgery nor do I wish to deal with orthodontics for over a year. I have had braces before when I was younger and do not want them again. I want my chin to look masculine and large but not abnormal. At the moment my mouth and nose stick out farther than my chin. I would like my chin to go out farther than, or at least in line with my mouth. Any advice or help you can offer is very much appreciated.
A: Thank you for sending your pictures. Your chin deficiency is significant enough (at least 12 to 15mms) that a chin implant alone will not suffice. No chin implant is made that can bring the chin far enough forward. Rather than an implant, you need a chin osteotomy (not a jaw osteotomy) which is to cut and move the chin bone forward. That will bring the chin forward about 12mms. In addition, it also has the advantage of vertically lengthening the chin which an implant alone can not do. If you then add a chin implant in front of or on top of the chin osteotomy, you can then get the more ideal result that you are after from a horizontal projection standpoint in a profile view.
Dr. Barry Eppley
Indianapolis Indiana
Q:I had a genioplasty to move the chin forward and now i want to do another surgery that doesn’t involve implants to make the chin wider. Is that possible and will the chin resorb after awhile because of splitting the chin and expanding it in the horizontal direction?
A: As you have discovered, moving the chin forward by an osteotomy will usually make it appear more narrow or tapered. This is because of simple geometry. If you move the front part of an arc forward (think of the lower jaw as u-shaped or an arc), it will make the overall shape of the total arc longer but more narrow in front. For this reason in male patients, I evaluate the front shape of the chin very carefully so if an osteotomy is performed for advancement, and the patient wants the chin to end up wider, I factor that into the osteotomy design and plan a central osteotomy with expansion.
Certainly a second chin osteotomy can be done and the downfractured chin segment split and expanded. It will be held apart by the necessary plates and screws needed to fix the overall osteotomy into position. This should not cause the bone segment later to undergo any resorption. A simpler method to get chin width expansion is to place a chin implant in front of or on top of the bone. There are chin implant styles that provide lateral fullness without any significant horizontal advancement and they would be a good choice here also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: i am going to have my chin shortened by cutting the bone, a procedure known as a vertical chin reduction. But I wanted to know something that is very important to me. After the surgery, the people that know me which i see everyday, will they see the difference in my face without me telling them? Will they know I have had some type of surgery? I am worried that they might say something like ‘Hey, what happened to your face?’ or something like that.
A: It is perfectly normal to assume that everyone that sees you after surgery will know exactly what you have had done. In reality, we give other people too much credit when it comes to perception. Most people, other than those who know us closely, see our faces in a more overall impression but not a lot of detail. Known as a facial gestalt, it is the image of our face people know, not the specific details. Therefore, after surgery people make see some difference (hopefully positive) but can not usually put their fingers on what was done. They will perceive that you look better, more refreshed, etc but they rarely can tell what part of the face was changed.
This is particularly true in anti-aging facial surgery (facelifts, eyelid tucks etc) but is also true in structural facial surgery. (rhinoplasty, otoplasty, facial implants, etc) Just because you know it doesn’t mean everyone else will. This is also because of another basic human characteristic….we are all more focused on ourselves than anyone else. Almost every human is more interested in how they look as opposed to how other people look.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have a problem with my profile. I wish it would look normal or see my jaw line. I always wished to see it. I think this is because I used to sleep with my mouth open when I was a child. I also a rhinoplasty by a bad doctor who made my nostrils asymmetric.:( This was 4 to 5 years ago. I went to someone who offered the lowest fees since I wasn’t earning much at the time. I would like to come to the states from Egypt for corrective surgery.
A: When most people talk about happiness with their profile, they are almost universally referring to the position of their chin. Based on how the lower jaw (mandible) grows and the bite (occlusion) comes together, the horizontal or forward position of the chin will be affected. For most it is an issue of being too short or not ‘strong’ enough particularly in men. Too much chin is far less of a problem although it does exist and it is more of a concern in women rather than men.
Correction of chin shortness can be done with either an implant or osteotomy. (moving just the chin bone forward) Which is better is determined by multiple factors including the amount of chin shortness, age of the patient, and the position of other chin dimensions. (e.g., vertical height) How much or far forward the chin position should be moved can be determined prior to surgery with computer imaging.
Nostril asymmetry after rhinoplasty is not rare and does not necessarily occur because of a ‘bad’ surgeon or that the operation was performed incorrectly. Even a rhinoplasty executed perfectly can still cause some differences in the shape of the nostrils after all is healed. The nostril shape is influenced by the support of the lower alar cartilages and the overlying skin. Both of these can be altered by the healing forces after rhinoplasty, particularly in the soft triangle area of the nostril where there is no cartilage support to resist the contractile forces of scarring. Secondary correction of nostril asymmetry is possible through cartilage or chondrocutaneous grafting of the nostril rim.
Dr. Barry Eppley
Q: I have seen your chin osteotomy video on Youtube. I’m from Vietnam. May I have your advice? I really need it. I had my chin done about 6 weeks ago. My chin bone was cut and moved forward about 8mm and now I have 3 small pieces of stainless steel in my chin bone. (like small rings). My doctor says that it’s ok to have those stainless steel in my chin for the rest of my life. Is that right? And the sad thing is that I regret that I had my chin cut. In fact, I just wish I hadn’t had the surgery. Should I now have my chin bone moved back? Can everything be like it was before or would my chin just be weaker? Can I get rid of that stainless steel in my chin if I have my chin moved back to its place just like it was before?
A: I have never had the experience in my Indianapolis plastic surgery practice of a patient ever regretting having their chin bone moved forward. This is a completely avoidable concern by using computer imaging prior to surgery. The chin is one of the two (the nose is the other) most easily and accurately computer imaged areas of the face. You can know precisely before surgery what it will likely look like afterwards. I am assuming that the regret from this patient is that they do not like the ‘new look’. Maybe it is moved too far forward or maybe it shouldn’t have been done at all. This is clearly a preventable case of surgical remorse.
While today’s facial bone surgery uses very small titanium plates and screws, the use of stainless steel wire (rings) is historic and perfectly safe. The use of bone wiring is still done in many parts of the world due to its lower cost. There is no concern with them there nor should they ever need to be removed.
Just as the chin can be cut and brought forward, it can be brought back to where it once was. This is much easier and quicker than the original surgery. If that is what one wants to do, I would do it within three months of the original surgery since there is minimal bone healing at this point. Chin osteotomies usually take at least six months to become completely healed back together. The use of wires or plates does have to be done to hold the bone together so it heals properly. The key to moving the chin back is to tighten the mentalis muscle back together well. Since it has been stretched out and expanded, it needs to be shortened and tightened once the bone is moved back and set. If not, you will end up with soft tissue sag known as a witch’s chin deformity.
Dr. Barry Eppley
Q: I would like to know what the rate of satisfaction is amongst patients that have had chin osteotomies or chin implants when actually they should have had lower advancement jaw surgery? Are they happy with their appearance or do they feel their top teeth extend out too much when they smile?
A: The short answer is yes. But that answer needs a more detailed explanation. The key is proper patient selection and understanding that a chin implant or osteotomy for a mandibular deficient patient is a compromise operation. It is treating the symptoms of the problem and not the primary problem. In other words, one is camouflaging the real defect and accepting whatever (if any) functional problems that may exist.
The idea treatment for a mandibular deficient patient with a malocclusion (Class bite relationship where the lower teeth are behind the upper…an overbite) is orthognathic surgery. Specifically, a mandibular advancement osteotomy with preparatory and postoperative orthodontics. While this is a very effective operation, it requires a commitment of several years of orthodontics, an operation, and the risks of damage to the inferior alveolar nerve. (some permanent change in the feeling of the lip and chin) The decision for mandibular advancement surgery, therefore, should be based on one’s age and the degree of malocclusion. You must balance the risks vs the benefits like any surgery. If one is young with more than several millimeters of overbite, this should seriously be considered and even done. In patients who are older, often with even more significant overbites, the enthusiasm for this surgical effort is often not there. Camouflaging the jaw defect and getting a better profile and improved facial proportions through a simpler chin implant or osteotomy has a lot more appeal.
In my Indianapolis plastic surgery experience, I have never had any unhappiness amongst patients who has chosen the isolated chin route. Nor has it been reported to me that their upper teeth stick out too far when they smile.
Dr. Barry Eppley