Your Questions
Your Questions
Q: Dr. Eppley, two years ago I had jaw advancement and sliding genioplasty surgery. Although my face symmetry has improved dramatically, this surgery has left me with lower lip incompetence. There is a 5mm to7mm gap between my top and lower lip when my lips are in resting phase, and although I have no evident mentalis strain when I force my lips to close, I would like to know if anything can be done to correct this lip incompetence. I have read that mentalis resuspension can work but I am not sure if this applies to me as I do not know the source of my lip incompetence (though I suspect it has to do with the mentalis muscle). Please see a before and after picture demonstrating the change in my lower face shape/size as well as my lower lip incompetence.
A: Any lower lip repositioning downward after any intraoral procedure that involves an incision inside the mouth at the chin area disrupts the mentalis muscle. Whether the muscle was adequately resuspended or not I would have no idea. But when the lower jaw is advanced combined with a sliding genioplasty, the amount of soft tissue to cover over the chin may simply have become ‘inadequate’ or stretched. This is reflected in the lower lip position which is affected by being pulled downward. Whether you can overcome the lower lip position by mentalis resuspension alone is suspect. That alone is unlikely to hold the lower lip upward and reduce the incompetence. This is a problem of tissue deficiency not just one of tissue malposition. The mentalis resuspension would have to be combined with other maneuvers to have chance of success. The addition of dermal-fat graft on top of the muscle suspension and a V-Y mucosal closure would be needed to end up seeing any improvement in your lip incompetence.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a bimaxillary osteotomy in August 2002 although was not at all happy with the results due to a advanced upper jaw and the genioplasty height was too long. I had corrective surgery in February 2003 to correct the upper jaw and genioplasty as well. I have read that this forms scar tissue and if I underwent a third genioplasty to shorten the chin slightly and to advance the chin forward and then have the chin muscle reattached or stitched in a more favorable position to reduce the lip incompetence and improve lower lip symmetry is this likely to be risky due to two previous surgeries done 10 years ago? From this information can you tell me if I’d be a suitable candidate or not and explain possible risks?
A: Thank you for sending your pictures. My perception is that your chin is too vertically long which is very evident on your x-ray. (although it looks longer on the x-ray than it does in your pictures) This would also account for for lip incompetence/sag. In theory, a bony genioplasty that brings the chin forward and shortens it slightly should be beneficial for both aesthetic and functional issues. My only reservation is that you have had two prior genioplasties and at least the second one should have addressed both of these chin issues. I am curious as to why you think this second or revisional genioplasty was ‘unsuccessful’.
In regards to your jaw angles, your x-ray show a high jaw angle and a shape that often occurs after a sagittal split mandibular ramus osteotomy in which there can be some reshaping of the angle with accentuation of the antigonial notch. While on the x-ray jaw angle implants look like they would be helpful, I am a little concerned about that when doing the computer imaging of you. Your jaw angles are a little wide naturally and even just vertically dropping them down may make your face look too full or ‘bottom heavy’. That may be particularly so when bringing the chin forward and vertically shortening it.
I have done some computer imaging from three angles and on your x-ray to get your thoughts on these potential changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering having jaw surgery. We have email conversed before and I am impressed with your perception and knowledge. I hope you will help me in my search for answers. I have attached photos for you to review if you so choose. I wore braces in the past and had no teeth extracted. My orthodontist says I have a Class I occlusion. As you can see, I show 1-2 mm of upper teeth at rest. When I smile, I show all of my upper teeth. When I laugh, I show 2-3 mm of gum. When my teeth come together, my lips don’t, so I have have to strain to close them. This seems to have resulted in my chin having a dimpled look almost as though there is a “fullness” of something. What bothers me is the protrusion of my mouth above and below the lip area, the crease under my lower lip, and the straining of and dippled look of my chin. I like the position of my chin and don’t want it pushed back if my jaws are moved back. I’m not sure if I would aesthetically look better if my jaw were moved back 2-3 mm. I don’t desire that my lips look a lot smaller. Do you have any thoughts???
A: My overall thought is you are not a candidate for major orthognathic surgery. You have a Class 1 occlusion and the aesthetic skeletal maxillary and mandibular problems that it is causing does not justify bimaxillary (maxillary and mandibular setback) surgery. While it can be done it is, so to speak, a long slide for a short gain…and not without some significant risks of morbidty. The magnitude of the problem and its potential benefits does not justify the effort for what is to be achieved. In short, the balance of benefits vs risk is not favorable.
I think there are some other alternatives, however, that are more appropriate for your facial problems. You have a horizontally short chin and mentalis muscle strain. That would be better treated by a sliding genioplasty to move the chin bone forward and give you lower lip conpetence. That would also improve the mentalis muscle strain and perhaps some of the dimpling. As for the upper lip, I question whether anything should be done for just a few millimeters of a gummy smile at maximal smile excursion. I might consider a simple levator superioris muscle release and vestibuloplasty only to blunt the upper lip excursion seen on maximal smile.
Dr. Barry Eppley
Indianapolis, Indiana