Q: Dr. Eppley, I hope this email finds you well. I have always been self conscious of my small head and weak Jaw. I recently had custom jaw and chin implants placed 7 months ago. I am happy with the results, especially with the chin, but would like to go with something bigger at the jaw with more support at the side between the jaw and chin. I assume I would need an inferior drop to the jaw, where my prior implants had none. I wanted to know how feasible this is to do from a safety standpoint and how the recovery would be compared to the original?
Regarding my forehead, it narrows inward and is concave compared to my zygomatic arch. I saw that you perform temporal implants with amazing results. I just wanted to know if these implants will feel natural once they are placed?
Finally, what kind of costs am I looking at for these procedures? I would want custom implants again for the chin/jaw but I don’t know what you would recommend for the temporal area. I would of course defer to you for both decisions. Finally, how much would these procedures cost in total if done together versus done staged?
A: Thank you for your inquiry. I would need to see pictures of you to give specific answers but I can provide the following general comments.
Since you have indwelling jaw angle implants in place that do not appear to provide any vertical elongation, new jaw angles can be placed. It helps that you have existing pocket so, in theory, the swelling and recovery would be less. (I assume your custom implants are made of silicone. Releasing the implant pocket and dropping the jaw angles down further is not a safety concern.
Based on your description of your temporal deficiency, it sounds like it goes all the way up to the forehead. Thus what you need would be what I call extended and Zone 1 and 2 temporal implants. All such temporal implants are placed on top of the muscle but under the fascia. Patients do not report any problems with such temporal implants feeling unnatural.
As for cost I am a but unclear as to how your current chin and jaw implants were made when you say custom. I assume this was done off of a 3D CT scan. If so that same scan can be used again. I will have my assistant Camille pass along the cost of the procedures if done together during the same surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I’ve given it a lot of thought and done some research over the internet. I’ve been having problems resulting from a previous jaw/chin reduction. And I really want my face bone structure to go back to where it was, or close to my original chin/jaw line. I need help and really want a chin/jaw implant(s).
See my chin in 2013 CT scan. A surgeon reduced my chin in 2013, I had a CT scan in 2014 and realised the surgeon took off about 4.27 mm. Until this day, the soft tissue (chin area) just has never felt right. It feels out of place, uncomfortable. I’m always pulling my chin skin down. The chin skin dips down when I smile. (side profile) I have 2 new dimples. My chin area, just right below my lower lip(right side), protrudes when I smile. (very noticeable) I hope this is not to do with mantalis suspension. The stitching line which the surgeon has done does look lower than my original mantalis line along the gum line right below my lower teeth. Saliva also drips, when I sleep, drips down the corner edge of my right side lower lip (I’m not so bothered. But I don’t know if it’s implication of any issue?
I really want my old chin back with a chin implant; hopefully it will solve some problems. I’d rather have chin implant incision under my chin, it sounds like the incision inside the mouth can affect the muscle or tissue affecting the lips?
1. Is it possible, that I have my chin augmented so that it will be the same as my original chin in 2013 CT scan? (Unfortunately, the CT scan in 2013 is all pictures, no raw data, so I don’t know if that CT scan can help in making a chin implant to achieve the original chin size or length?)(However, my new 2014 CT does have the raw data needed to make custom jaw/chin implants. But my chin has been reduced on 2014 CT)
2. What kind of chin implant will I need, vertical or horizontal? (I dare not do chin sliding osteotomy.)
3. Logic tells me I will also need to do a jaw line augmentation to line up with my desired chin. I’m thinking it’s best to do a custom chin/jaw implant. So will this be 3 pieces implant or 1 implant that wraps around? For best results.
4. What material will the implant(s) be made of? If silicone, what kind of silicone exactly? Heard of silastic but usually associated w/ chin implants.
A: Thank you for sending the pictures and a detailed description of your chin concerns. Based on the pictures I assume your chin reduction was done through an intraoral approach. An intraoral approach to a vertical chin reduction should be done by a vertical wedge ostectomy through the middle of the chin bone (vertical reduction bony genioplasty) to preserve the attachments to the bottom of the chin bottom to prevent soft tissue ptosis. (or an empty soft tissue pocket as the chin tissue will fail to adhere to the bone) In looking at the CT scan, and it may be a function of your drawing, it looks like just the bottom of the chin was cut off. (a lower chin ostectomy) That would be a very unusual approach to a vertical chin reduction but would account for many of your current symptoms. This you have two current problems, an aesthetically shorter chin (which perhaps may not be a concern for you) and soft tissue chi ptosis/mentalis sag.
The optimal way to correct these chin concerns is a custom chin implant with a jawline extension as a one piece implant. (one could argue that a vertical lengthening bony genioplasty would also be appropriate but you have excluded that option. While there is no true way to know exactly match your previous chin (since the DICOM data is not available), the design could be reasonably guessed. It is only a question of how far back along the jawline one wants to go. This looks like it would be a pure vertical lengthening chin implant. Such custom chin implants are made of solid silicone material. The term silicone and Silastic are synonymous. The name Silastic was trademarked in 1948 by the Dow Corning company for their silicone polymer product and it is name that is still occasionally used today been though the Dow Corning company no longer makes any aesthetic silicone products.
This custom chin implants should fill in the loose tissue at the bottom of the chin and eliminate that feeling of looseness of the soft tissue at the end of the chin. The only residual concern is that of your salivary drooling and that raises the question of whether mentalis muscle resuspension should be done at the same time. If you have lower lip incompetence/sag I would say yes. But if not I would leave it alone and see effect the chin bone restoration achieves.
Dr. Barry Eppley
Q: Dr. Eppley, I have a large square chin implant that was placed 6 months ago that I am not happy with. As the swelling went away it became apparent quite quickly that it was not whaI wanted. The improvement is too small and it has little if any square definition from the front view. I have a 3-D jaw model done after the implant which I have sent to you. I am requesting a chin implant that is 19 mm thick and 3 inches wide from the front. I know that the implant is going to be fitted directly on the bone which means that it is going to curve around the chin to the side.That being said the squareness and the size of the implant is going to deviate from the criteria that I am trying to achieve because as the implant proceeds backward from the mid point of the chin it is going to take a different shape and size. Knowing that to maintain the squareness of the implant along the 3 inch width we need to increase the size of the implant as it proceeds backward from the midpoint of the chin. Please tell what you think.
A: I have received your 3-D model of your mandible with the existing chin implant you now have. The current implant you have appears to be a Style I square chin implant of 9mms horizontal projection. It is significantly asymmetric due to placement with the right wing of the implant being very high and right up against the mental nerve location.
As to your dimension request for a new custom chin implant, this needs to be carefully thought over as 19mms of horizontal projection is significant and would be roughly twice of that you have now. The 3 inch squareness width, or 7.5 cms frontal width, is considerable and is about a 3.5 cm width increase over the implant you now have. It would be unusual to need more than 5 or 5.5 cms in most men to develop a square chin look from the front. With such a wide frontal square width, this necessitates the need for a wide width around the corner of the implant as it transitions back into the side of the jaw.
I would be careful to oversize the implant and it is easy to do. It may seem that these dimensions are needed/desired, but it can be surprising as to how these translate to one’s appearance once in place due to the overlying soft tissue thickness. You do not want to end up with a ‘Jay Leno’ chin afterwards which is way too big and result in the need for revisional surgery.
I would suggest some smaller dimensions to the custom implant, more like 15mm in horizontal projection and 5.5 cms square chin width.
Dr. Barry Eppley
Q: Dr. Eppley, I am considering more about the chin implant and appreciate the computer imaging that you have done. My question is do I really need to enlarge my chin so much? Actually as far as I know the largest chin implant by Medpor enlarges chin by 7mm. Actually it looks better from the side view, but I am also was worried about asymmetry of the face from the front view. So I thought to put the Geniomandibular Groove implant to right side only to correct it. But while would it correct the asymmetry, I would not look better from the side view. By using the Medpor RZ chin implant, is it possible to trim in operation or I would need to order jaw model by CT for custom implant because of the asymmetry?( http://eppleyplasticsurgery.com//blog/tag/custom-chin-implant/ ) How long would it take to get and much would it cost? Do you think I need a custom chin implant?
A: The imaging shown is just a point to begin the discussion of the changes you would like. Certainly the amount of horizontal chin projection can be less. But I would not go less than 7mms because anything less than that would not make much of a noticeable change.
Geniomandibular groove implants will not provide much horizontal projection, maybe 1 to 2mms. They are used primarily for vertical lengthening of 3 to 5mms and to fill out a notch at the lower mandibular border.
Your best off-the-shelf chin implant option would be the Medpor RZ extended square implant of 7mm projection. The wings of the implant could be intraoperatively modified to try and compensate for your facial asymmetry along the jawline. I would expect improvement in the asymmetry but not ideal correction as this is a stock implant not a custom one…and your problem is obviously unique to your anatomy and not a ‘stock’ problem.
While custom implants are ideal for any patient, it is always a question of whether the cost is necessary for the amount of aesthetic improvement. That will always depend on the patient’s problem and how asymmetrical or unique the bone problem is. At $3500 extra costs to get it made, one does have to give that good thought. I think it depends on what one is prepared to live with when it comes to the result. In your case, if you can live with improvement but not ideal symmetry than I would go with an off-the-shelf implant.
Dr. Barry Eppley
Q: Dr. Eppley, I am writing to you because I am interested in getting a custom implant made for my jaw/chin to improve my profile. I currently have a chin implant that I am not satisfied with because it only advances my chin horizontally. I am interested in vertically lengthening my chin. I saw on your website the case study of vertically lengthening using a custom implant and I wanted to see if this could help me to achieve the results I desire. Specifically, I want to know if a custom implant can both vertically and horizontally lengthen my chin and front of my jaw. I have attached some pictures of what my face looks like before and after the original chin implant surgery.
A: In looking at your desired chin change, there is no question that a significant vertical lengthening as well as some further horizontal advancement is needed. There is two ways to get there.
1) Custom Chin Implant – There is no off-the-shelf implant that can remotely make this amount of chin change. Based on a mandibular model from a 3-D CT scan, I can custom make an implant to the exact specifications that will work. Your existing chin implant would then be replaced by this new one. This is the ideal implant approach and adds additional costs to the base surgery to make the actual implant and have it ready for surgery. (the CT scan cost would be in addition and is based on the facility fee charge)
2) Chin Osteotomy – Keeping your current chin implant in place, a chin osteotomy is performed above it and the entire chin with implant is brought forward and vertically lengthened with an interpositional hydroxyapatite block used as a graft. This is what I call the extreme chin augmentation approach, combining an implant with an osteotomy.
In looking at your pictures, I think #2 is a viable option but I would need to confirm that by looking at a lateral cephalometric x-ray. (standard orthodontic/oral surgery film.
Dr. Barry Eppley
Q: Dr. Eppley, I have facial asymmetry of which my left eye area is a big part of why it looks the way it does. I am interested in brow shaving and a canthopexy to improve the eye area. My biggest concern with orbital rim shaving would be losing frontal bossing over that orbital rim. Let me ask you if you have ever performed shaving of the orbital rims for the purpose of better balancing facial asymmetry?
Regarding chin implants. Given your extensive experience with these, especially in ideal jaw surgery candidates who refuse surgery (retrognathic lower jaw), I’d like to ask you if it’s a realistic possibility to recreate the appearance of a jaw when it is in a prognathic position, using a chin implant with wings? What I mean is when I slide my jaw as far forward as I can, creating what is dentally considered mandibular prognathism, I reallylike the aesthetic appearance it has on my jawline, probably because my jawline is retruded by default so when I manipulate my jaw into a prognathic position it actually just ends up looking relatively normal (with the exception of my lower teeth pushing my lower lip forward which is the only giveaway). Basically I’m asking if a chin implant with wings can provide anterior projection to the entire jawline, not only the forward most point of chin but also along the mandibular body of the jaw, bringing most of the jaw (except the mandibular angles) more forward relative to other parts of the face, like what happens when you push your jaw forward in your face.
Also another big question Ive always had about chin implants is how does the placement of a chin implant effects the lower lip? Do chin implants push the lower lip forward at all? And what about augmentation of the chin groove, can this be moved “forward” or augmented at all to avoid the formation of a huge indentation in the chin groove between the bottom lip and chin implant? As it would seem the larger the chin implant you use, the deeper this groove would become.
A: In regards to orbital rim shaving is done through an upper eyelid incision, it removes the bottom portion of the orbital rim not its anterior projection. So there would be no risk of losing frontal bossing which is a horizontal brow feature. Inferior orbital rim shaving is done almost exclusively in cases of facial/brow asymmetry. There would be no other reason to do it. The result is subtle, not dramatic, and is in the range of 3 to 5mms depending upon the degree of superior orbital rim asymmetry.
If you are jutting your jaw forward and getting the desired look, then a chin implant with match that horizontal result. It may be a little thinner at the sides. The most ideal thing to do is to make a custom chin implant which would overcome that issue.
The lower lip never changes position no matter whagt is done to the chin. That can only change with an entire jaw advancement procedure. You are correct in that the labiomental groove will be come deeper as the chin position changes below it but the labiomental groove is not changes by an isolated chin procedure, implant or osteotomy. That can be overcome with a custom chin implant which builts up that area whereas a conventional chin implant does not.
Dr. Barry Eppley