Your Questions
Your Questions
Q: Dr. Eppley, I am interested in chin ptosis repair surgery. I am emailing you to see if you are able to correct my chin deformity from a previous surgery five years ago. I had a chin implant removed from twenty five years ago because it made my chin look very wide and bulky. The surgeon performed a sliding genioplasty for a 3mm advancement and a lipectomy which left me with a depression and a bulge. I now have redundant skin hanging and my chin is very flat and wide and misshapen. If there is anything you think you can do to correct this please let me know.
A: Thank you for sending your pictures. What you have is chin ptosis and a residual wide chin. (since I do not know what you looked like before I can only go by your current picture) The best approach for your chin ptosis repair is a submental chin reshaping procedure to taper your bony chin and get rid of the overhanging tissue. This is the most assured way to get a better chin contour by dealing with both the bony and soft tissue components of the problem from the underside of the chin. As your chin problem is primarily that of loose skin this is particularly the best chin ptosis repair approach for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am contacting to find out more info about chin ptosis correction. I am 26 years old and had a chin implant that I strongly regretted. It was removed about six months ago. I notice that my chin has not returned to its original shape and size as I had been told that it would. There seems to be excess tissue underneath my chin and I miss the taut appearance that I used to have naturally. Just curious about what is involved to correct this issue and the potential cost. My incision was made underneath the chin, not intraorally. Thanks a lot for any info.
A: Unless the chin implant was fairly small and removed shortly after insertion, rarely do the chin soft tissues return to their exact shape as before surgery. All face and body implants are, to some degree, tissue expanders and they can create some overlying soft tissue changes no matter how small they may be. The approaches to chin ptosis repair are of two fundamental types, resuspension and excision. Sagging chin tissues can be resuspended, excess chin soft tissues can be removed. Which approach is best depends on the nature of the chin problem. I would need to see some pictures of your chin to make that chin ptosis repair determination. My suspicion is that you have a very small amount of soft tissue sag at the bottom of the chin that can be easily solved with a submental tuckup procedure. As long as the lower lip position is good any soft tissue sag off the chin bone is usually best treated by a chin ptosis repair using excision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a problem with the mentalis “balling up” when I try to elevate my lip after having a genioplasty. Prior to the genioplasty I had an indentation (not really a cleft but a small ridge) in the lower middle of my chin, this since is gone and simply looks like a ball of tissue when I elevate my lip (at rest it looks okay). I did consult with a local surgeon over a year ago who then performed a mentalis resuspension. This showed some improvement but afterwords, due to still having the “balling” found out that he never fully released the mentalis and he’s recommending releasing the entire mentalis and resuspending again. I’ve been doing some research about mentalis resuspension. One technique goes intraorally to do a wide release of the mentalis but also makes a small incision under the chin until the mentalis is completely released. Once the mentalis is fully released it is suspended intraorally and then the chin pad is anchored rom below. Do you think this will work? My main objective is to reduce (or eliminate if possible) the balling effect, hopefully returning that nice indentation (which I feel is the main reason the area balls up) and hopefully reducing my lower teeth show (full competence would be nice however I’d be happy with a mere improvement). Please let me know if this is something that you perform and if it’s something you’d feel comfortable with.
A: As you know there are different variations and extent of mentalis muscle releases. Depending upon how much the mentalis muscle is released will determine how much it can be resuspended. The mentalis muscle has its origin on the bone in the incisive fossa of the incisor teeth superiorly and inserts inferiorly into the skin of the chin. (not really the bone on the bottom of the chin) It is the insertion point of the muscle that actually contracts and pulls the skin upward. Thus when you are talking about a balling up of the muscle when you elevate your lower lip, that suggests that the problem may be exactly the opposite of what you think. I would question with your history if releasing the whole insertion of the mentalis muscle from below is really going to correct this balling up issue. Rather that anatomically suggests that the balled up area of muscle may represent the fact that the insertion point of the muscle in that area has been lost. However given that it is very difficult to re-establish a long-standing disinsertion point of the mentalis muscle (chronic scarred muscle contracture) the only real effective option may in fact be complete mentalis muscle insertion release. This does require a submental incision to really fully release it properly. Once fully released then it would have to be resuspended intraorally.
That is a long answer to say that this full mentalis muscle release and resuspension would be the only hope of eliminating this balling up issue even though it is ‘anatomically incorrect’ when you look at how the muscle moves and its origin and insertion points. That most certainly could be done under a sedation and local anesthesia approach like before.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to find out if I am a good candidate for chin ptosis repair. I have been doing some research online and found your name. I am interested in a possible facelift later but wanted to address my chin at this time as it is a problem I have had my whole life. My chin pad just seems to fall off of the end of the chin bone and looks worse when I smile. Thank you.
A: You certainly do have a ptotic chin pad and it is just part of your natural development as you have stated it has been there your whole life. That can be markedly improved or eliminated by a submental technique for chin ptosis repair where the extra and loose hanging chin pad is removed and tucked in from underneath. Yours is not an issue where the chin pad is pulled up but rather pulled under and removed. This leaves a fine line scar in the submental skin crease area. This is a short procedure that can be done under IV sedation that has a very minimal recovery as it appears your chin ptosis repair needs only soft tissue reduction and does not require any bone work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant put in and removed within a few months about 4 years ago. I have slight chin ptosis, and read about “routine” procedures to reattach/tighten/lift the chin pad, like what you discuss above, but when I google search, I find no one who does this . I have googled “raising the introral sulcus”, “correcting bottom tooth show”(no one seems to have any suggestions for this), “correcting chin ptosis”, “submental tuck up” (which you have also talked about) and get like 2 results. and those that do these procedures have like one photo on their website. I would also like projection higher up on my chin so that overhead light hits a small area on the chin, the rest in shadow. The implant I had before just extended the downward line of my jaw and increased the area that the overhead light would catch, making my chin look longer. I feel a feminine chin not only projects, but curves slightly upward at the end of the jaw. On your chin implant page, the 7th one down has a nice curve up, as do many of your patients, the 8th one down does not, nor does the one on the bottom of page 1–you just continued the downward direction of these jaws and I don’t think it looks right. How do you avoid that?? Thanks.
A: Correcting chin ptosis is anything but a routinue plastic surgery procedure. There is not much written about it because its correction is not easy and the results not always predictable. I have learned that the most predictable way to get sustained improvement is to do a lower periosteal/mentalis release, elevation of the chin pad by suture anchorage to a higher position on the bone, a V-Y lower lip mucosal advancement and a shortening vestibuloplasty. Combining all four maneuvers will always correct a some degree of a sustained chin pad repositioning and maybe some slight lower lip elevation.
Getting a chin pad that curves upward with implant augmentation depends on numerous factors including the presurgical shape of the chin pad, chin implant style and size (women usually do better with a central button style chin) and whether an intraoral or submental approach is used.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am writing to request for your thoughts in chin ptosis correction, which I found out through Q&A’s on your website. I had a fairly large chin implant removed due to infection 2 years ago, which left me with my current chin ptosis condition. The implant was in my body for 10 months, so the capsule is still left in me for horizontal projection. I am happy with the projection it gives, except that the capsule sits high part of my chin (just below my lower lip), and there is a difference between where my lower part of my chin bone starts and where the capsule lies. Since the primary concern is loose skin, I would love to have some form of skin-tightening or skin-cutting without showing the gap between my capsule and my chin bone. (in picture I am grabbing the loose tissue) I consulted about this issue with a previous surgeon who placed an chin implantl and he just didn’t know what to do. He told me he has never seen this level of chin ptosis, and he just ended up recommending another sliding genioplasty and chin implant. I am personally satisfied with my current forward projection through capsule, and I am not sure if I will need more chin augmentation.
A: By definition what you demonstrating by grabbing is a procedure known as submentoplasty. To me your ptosis is really submental in location and not on the chin point at all. A submentoplasty procedure involves a curved submental incision under the chin to remove skin and fat and tighten the neck. I don’t think that will get rid of all your submental ptosis because to do so would involve a longer incision that I would not feel comfortable doing in a male with your skin pigment and ethnicity. The best result comes from a direct necklift but a vertical incision should never be done on your neck.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have chin ptosis after the removal of a large chin implant. So what needs to be primarily done should be a mentalis resuspension. I am considering sliding genioplasty despite the risks of bone osteotomy, longer surgery time, and longer recovery time, only if it helps the result of the mentalis resuspension procedure. If genioplasty would have any negative effect or no effect on the mentalis resuspension procedure (i.e. more bleeding, swelling, more complications than the resuspension procedure alone), I would not want to have it done.
My question is, first of all, regarding [mentalis resuspension alone] vs. [mentalis resuspension + sliding genioplasty], would there be any difference in the result concerning the ptotic chin and lower lip disturbance? If there should be no actual difference, then I probably wouldn’t want the sliding genioplasty done due to longer recovery time and more risks. But, if the genioplasty should give any positive effect, I should consider it be done along with the mentalis resuspension procedure.
Secondly, my implant insertion and removal were both done by intraoral approach. Should the mentalis resuspension procedure be performed by intraoral approach again?
Lastly, you have mentioned the disruption of the attachments of labiomental sulcus as the cause of lower lip eversion disturbance. By the “attachments of labiomental sulcus”, do you mean the mentalis muscle attachment to the bone? Or is there any other muscle involved in this area? Does labiomental sulcus muscle repair simply mean resuspension of the mentalis muscle? Are there any other muscles that should be repaired to fix the attachments of labiomental sulcus?
A: The mentalis muscle suspension is infinitely improved by the concomitant sliding genioplasty as this procedure addresses one anatomic element that intraoral suspension does not…excess skin and subcutaneous tissues. Bone-occupying volume expansion with muscle tightening addresses all the issues of the ptotic chin problem.
The intraoral approach has disrupted the superior attachements of the muscle and, if only the mentalis muscle resuspension was going to be done, then you would do an intraoral approach for repair.
Labiomental sulcus disruption means the complete loss of superior mentalis muscle attachments. That is addressed in the intraoral mentalis muscle suspension procedure through the use of bone anchors.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty two years ago and have suffered with iatrogenic chin ptosis since. I have read in your writings that there is the possibility to resuspend the mentalis muscle using bone anchors to a higher level. Also you have recommended a VY lengthening of the mucosa of the lower lip at the same time.What is very hard to find out is how the patients feel after this surgery concerning to the ability to move the lip sidewards and forward and the movement to evert the inferior lip. Is this type of lip movement uncomfortable afterwards? How is the patients’ sensation moving their lips after a mentalis resuspension? Does it continue to be uncomfortable because of the devascularing nature of the intraoral incision or the mentalis muscle turning it out into an atrophic scar? My concern is that my most important issue that I would really like to repair is functional and I would really like to correct the discomfort I have. Would really appreciate if could please write a few lines about how patients feel moving their lips after this procedure.
A: Chin ptosis after a chin osteotomy is very unusual as the bony movement forward (typical direction) picks up any loose tissue. But it is possible if the chin osteotomy is used to vertically shorten the chin and move it backwards (not a good idea), if the surgeon does not tighten the now excess soft tissues. In my experience with chin ptosis repair, complaints about difficulty with moving the lips or loss of feeling have not been voiced. This does not mean that they may not exist, but that they were not considered significant. I suspect I have have not heard of them because they do not turn out to be problems after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a genioplasty with iliac bone grafting five years ago. The result was disastrous. I got a long and prominent chin and it was so completely different than I planned. After that, I had several revisions to get an imprrovement. For example the jaw bone had been suspended back and I also I had a chin reduction. This resulted in an unpleasant scar under my chin. Now the chin soft tissue is scarred and hanging down. If my mouth is closed I feel a strain on the chin muscle. During relaxation my lower lip hangs down showing my bottom teeth. The mentalis muscle shows a strong contraction.
I couldn´t find any surgeon who had enough knowledge in this specific area of genioplasty revision and chin ptosis. In various discussion forums about this topic I came across your name. I hope that your skills and experience in this special field could be helpful in my case. Is there any possibility to solve my problem and what could this be? What is the probability of improving my situation? Your help would be very much appreciated. I have attached some pictures for you to see my chin problems.
A: Your chin surgery history and outcome has certainly been that of a nightmare. What you currently have is chin ptosis with severe contracture. What need is an intraoral approach to release the scarred chin tissues, mentalis muscle resuspension with suture anchors and a V-Y vestibular closure. Your submental scar should also be released and revised. The divot (indentation) in your chin would be treated by the placement of a small dermal-fat graft at the same time. All of these procedures would be done simultaneously address all of your current chin problems. My experience in doing these chin ptosis repair procedures is that improvement is always obtained, it is just a matter of the degree of improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: There seems to be a multitude of people out there with chin/lip problems arising from intraoral surgery who don’t know where to turn or what to rely on to remedy their situation. Mostly their problems are attributed to mentalis detachment/loosening and scar tissue, particularly in the labiomental fold region. Chin/lip deformity poses a significant quality of life issues and must be taken seriously. A case study of scar revision in this instance, with before and after photos and details of the surgery, would be of great assistance. Mentalis resuspension seems straight forward enough if its loosened or detached from its origins. The question in my mind with regards to scar tissue excision, is how much mentalis muscle in the labiomental fold or chin pad region, can be safely excised before the mentalis can no longer function properly?
A: Ptosis, or sagging, of the soft tissues of the chin can occur after any form of chin surgery done through an intraoral (inside the mouth) approach. When it occurs, one surgical method to put the soft tissues back onto the chin bone is mentalis resuspension. This is fairly way to do and the most important technique for the procedure is how the muscle is secured back to the bone.
Generally speaking, the only scar tissue that ever needs to be removed during any chin revisional surgery is the scar capsule around an existing chin implant. (if the implant is being removed) This needs to be removed because it will not allow the overlying muscle to heal back onto the bone.
Dr. Barry Eppley
Indianapolis Indiana
Q : I had a sliding genioplasty surgery with bone graft on my jaw angle on the 17th of august, before the surgery when i smile my chin tissue protudes downward (chin ptosis) the oral maxilofacila surgeon told me he can fix it during the sliding genioplasty surgery, its been 3 weeks now, and when i smile my chin tissue still protudes downward, i told him about it and he said my mental labial fold has not heal completely thats why it protrudes downward, i think is cos he didnt move my chin forward enough. i wan to send photo to you so you can see what i mean, i really want to get this fixed asap.
A: Generally, a sliding genioplasty will pick up loose chin tissues as it comes forward. Thus correcting a pre-existing chin ptosis. It is not so much that the bone is advanced, but the mentalis muscle and the chin skin are pulled back over a longer bone surface. This is essentially the reverse of what happens when the bony chin is set back (not a good idea) as there is too much chin soft tissue that has less bone surface to be suspended and it will then droop.
Why your chin ptosis did not at least get some correction with the advanced bony chin is not clear. The one possibility is that the mentalis muscle was not put back or resuspended as well as it could be, thus negating the effects of better bony support. This is easily corrected at this early point after surgery as little actual tissue healing has occurred. More time and having the swelling go down further will not likely show an improvement. I would recommend re-entry and better muscle suspension.
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