Your Questions
Your Questions
Q: Dr. Eppley, I am interested in facial reshaping surgery. Can I get a longer and slimmer face with strong jawline and cheekbone through the facial reshaping procedures? If no, what type of procedure will I need and how much will the total cost be . I feel like I can trust Dr Eppley for these life changing procedures.
A: In looking at your pictures, I can recommend several facial reshaping procedures that would make your face longer and slimmer. These procedures include vertical chin lengthening (vertical lengthening chin implant vs. open sliding genioplasty), cheek implants, buccal lipectomies and perioral mound liposuction. The effect of these procedures is created because multiple hard and soft tissue changes are occurring in different dimensions. When all are combined the effect of increased vertical facial height (real facial change) and decreased facial width (more of a visual facial) occurs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin reshaping. I think my mid face and chin are long (I assume it’s easiest to fix just the chin). I’d like to reduce vertical height by at least a third and increase chin projection. I may also consider some work on my nose. (narrow bridge, hump removal, refine tip).
A: Thank you for sending your pictures. It is far easier to vertically shorten facial height by working on the chin. Midface vertical length can only be reduced by a maxillary impaction surgery which can only be done if one has true vertical maxillary excess. (too much tooth and gum show at rest)
Your chin appears long because of it is horizontally short and rotated backward. A sliding genioplasty can be done to bring it forward and to vertically shorten it at the same. To see how this would look, computer imaging needs to be done. To do this type of computer imaging analysis, I need non-smiling pictures from the front and profile views to get a non-distorted imaging. As beautiful as your smile is, it distorts the soft tissues of the chin and nose. This is the one time where smiling is not helpful!
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I found your website, and I was wondering if you could offer a suggestion in my case. I had jaw surgery twice several years ago. First, a 2-piece Lefort I, IVRO, and a jumping genioplasty was done. (I was a skeletal Class II with anterior open bite.) The surgery, in every aspect, was poorly done and I had a re-do Lefort I six months later. Again, the outcome was not good, and I underwent re-do 2-piece Lefort I, BSSO, and re-do chin osteotomy about 10 weeks ago (with a different surgeon). In this final surgery, bite correction was achieved, and in most respects, it was a success. But I am still unhappy with the appearance of my chin. I have significant step-offs from the first genioplasty. In the re-do, my surgeon shaved down the bone (no cuts) in the front, but did not address the step-offs. From the ceph x-ray, it seems the bony part of the chin is in the right place, but I have significant soft-tissue protrusion that I am very unhappy with. I believe the success of the re-do was compromised by the technique used by the first surgeon (not sure why he didn’t do a sliding genioplasty, as my chin was not terribly receded in relation to my jaw). I am concerned that a third procedure to “correct” the chin may cause more harm than good, but I am not sure. I am also not sure how much swelling I still have in that area. I did not have this amount of soft tissue in the front of the chin area before the first surgery. It appeared after the first surgery, and only increased with the most recent surgery. The step-offs are clearly visible from the front and side, in addition to my being able to feel them. Thank you for your time.
A: I am very sorry to hear of your very complex orthognathic surgery history. From a chin standpoint you had a jumping genioplasty (I have never liked this chin osteotomy technique) which has it own lateral step-off issues. Then the last genioplasty procedure burred down the front edge of the bone which is guaranteed to create a soft tissue excess issue. All of these genioplasty techniques understandably have left you with step-offs and some degree of soft tissue ptosis/sag. While you aren’t quite three months from the last surgery, I see no reason that your chin issues will improve with time. The best way in my experience to address these chin problems are from a submental approach for your genioplasty revision for chin reshaping. The step-off chin defects can be filled in and the chin sag removed with a submental tuck technique.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I did the chin advancement at your clinic about three years ago and attached is the current result. The vertical length of the chin is good and my face is now long enough. But I still feel the chin needs to be horizontally moved forward a little bit. You did a very good chin job at that time but my chin was quite short and the advancement was put to the possible limit. My question now is: Is it possible to do another chin advancement?
A: Good to hear from you and thanks for the long-term follow-up. I remember your case well. I do agree that the vertical length is good but it still remains horizontally short. One of the sacrifices for vertical lengthening is that there is a limit as to how much horizontal movement can be obtained. The question now is whether a secondary sliding genioplasty can be done to move it further forward. (or whether only an implant can now be used) Given that it has been three years, good bony fill of the osteotomy gap should have occurred. If there is good bone stock the answer would be yes. But the only way to know that for certain would be to check any x-ray. The best x-ray would be a 3D CT scan. That will definitely answer the question of adequate bone thickness. There is also the question of the indwelling metal plate which could be completely overgrown with bone. It may not be easy to remove to do the osteotomy and that is another factor to consider.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Should I take out a 10 year old chin implant (silicone button type) first several months before a sliding genioplasty? Or can it be done at the same session as the genioplasty? If the latter (keep chin implant in until genioplasty operation), will it affect the accuracy of the cephalometric analysis? What about scar tissue – should it be removed first several months and healed up before the genioplasty? Which way is recommended to produce the result?
A: A sliding genioplasty is a good chin implant replacement method. It can fill the void left by the removal of the chin implant and replaces it with one’s own chin bone. There is no reason to stage the replacement of a chin implant with a sliding genioplasty. That creates an additional operation that provides no benefit to treatment planning or making the tissue bed any better prepared. The chin implant and its scar tissue layer against the bone can easily be removed and the sliding genioplasty performed unimpeded. It is not necessary to remove the capsule (scar tissue) up against the soft tissue side of the chin. The sliding genioplasty also provides the opportunity to creat different dimensional changes than an implant. (such as vertical lengthening, vertical chin shortening, chin narrowing/widening)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a crooked chin after genioplasty 6 weeks ago. After the swelling went down, the shape veers to the left. It looks lower than the right. My chin originally is very small and after this procedure it looks more sharp and just goes to the left. before surgery, i had slight asymmetry from an implant but the surgeon said he would improve it with genioplasty. What are my options?
A:At six weeks after a sliding genioplasty most of the swelling is usually gone. Residual swelling and bony remodeling will continue to evolve and, for these reasons, I always use the end point of three months to pout the final critical assessment of any facial bone procedure such as a sliding genioplasty. Whether what you are seeing now will be present in another six weeks cannot be predicted at this point. But for the sake of discussion let us assume that it does.
A crooked sliding genioplasty is the result of either an asymmetric bone cut or a bone segment that has rotated. Because most genioplasties have a central point of bone fixation (plate and screws), it is possible that the down fractured bone segment is rotated with the left side being slightly out more than the right. This is the most likely reason for what you are seeing now. There are two approaches to its improvement. One option is to adjust the bone fixation to reposition the chin bone segment. That is usually only possible in the first three months after surgery without having to recut the bone. The other option is to simply burr down the longer bone segment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if it would be possible for you to perform a genioplasty subtle enough that my friends and family will not instantly wonder what happened to my face. I plan to not tell anyone about my surgery, so this is important. I really only want it moved forward a couple millimeters at most so that it comes closer to sticking out as far as my lips. I’m fine with the shape of my chin and the shape of my jaw. The effect will hopefully be more like “oh look he grew into his face” and less like “what happened to his face??” How much recovery do you think I will need until I look normal?
A:You can certainly only move a sliding genioplasty a few millimeters (3 to 5mms) of that is all one desires. And in looking at your profile picture, I would say that is all you really need anyway. While it appears you are set on moving the chin bone I might point out that cutting the bone for that amount of small horizontal change seems like a big effort. Such small sliding genioplasty movements are usually only done with it is part of an overall orthognathic surgery of the jaws where one is already in the operating room asleep and bones are already being cut. But when done as an isolated procedure a chin implant seems far simpler with a much quicker recovery.
For a sliding genioplasty I would give yourself 2 to 3weeks until you look fairly normal and have an unoperated appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have several questions about vertical chin lengthening. They are as follows:
1) Given my case of wanting vertical elongation with some minimal horizontal projection, are my needs best served with a chin implant or a sliding genioplasty and which one in your professional opinion would you recommend and why?
2) I am primarily interested in a sliding genioplasty and would prefer to avoid an implant. In my case, would you be willing and able to do a sliding genioplasty on me instead of an implant?
3) Can vertical elongation be achieved with a sliding genioplasty?
4) With a chin implant, can vertical elongation be achieved?
5) I noticed that when I smile, my chin seems to jut out. However, upon closer observation, I noticed that it is because my entire face goes upward when I do smile. Would A chin implant emphasize this jutting out of the chin?
6) What a sliding genioplasty emphasize this jutting out of the chin as described above?
7) Since my chin seems to jutt out when I smile, it is possible for a sliding genioplasty to be done primarily for vertical elongation purposes and minimal forward movement?
8) Do you think I would have mentalis muscle strain with a sliding genioplasty?
9) If a sliding genioplasty is done, is there a chance that my lower lip might not be able to touch upon the top lip and would struggle to close my mouth? Is this is same as mentalis muscle strain?
10) Will the lip curl of my lower lip downward be exaggerated with a chin implant given that a chin implant primarily is done for horizontal projection and not for vertical elongation which is my goal?
11) With a sliding genioplasty, because the bone would be brought down and slightly out, will that create a more v-shape/heart shape look to my lower face?
Thank you so much Dr. Eppley and I look forward to your response.
A: In answer to your specific questions:
1) For pure vertical chin elongation, either a sliding genioplasty or a chin implant can be used. But the chin implant would have to be custom made to achieve a vertical lengthening since they are not manufactured in standard shapes to normally do so. I have done in either way for various patients and their affinity or disdain for an implant will determine the choice. Most, if not all, Asian women that I have treated or discussed this type of chin change are going to opt for a sliding genioplasty approach.
2) Your preference for a sliding genioplasty indicates that is the preferred choice for you.
3) Vertical elongation alone can easily be achieved with a sliding genioplasty.
4) Only a custom chin implant can achieve vertical lengthening.
5) and 6) Neither a chin implant or a sliding genioplasty is going to make this jutting out of the chin change. Whether it would make it worse can not be predicted.
7) A sliding genioplasty can be done in any dimension one wants. While it may be commonly done for horizontal advancement, that does not mean it has to be done for that movement. You seem to be under a misconception that it is somehow unusual or difficult to just move the move for vertical lengthening alone when it is not. That is the easiest movement to make for a sliding genioplasty.
8) Any change in the bone position of the chin runs the risk of creating a mentalis strain. It is not very common but potentially can happen.
9) Lower lip incompetence and mentalis strain are indeed related. Again it is not a very common problem to occur after a sliding genioplasty but is possible.
10) Since you are not interested in a chin implant, this question does not seem applicable.
11) Vertical lengthening of the chin by a bony genioplasty is a well known facial bone technique for making the face more heart shaped. This can be particularly aided by also narrowing the chin bone as it is lengthened.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant procedure last year with a medium silicone chin implant. The picture on the left (attachment) shows me right now with the implant, the picture on the right is me with a photoshopped chin projection. I downloaded this plastic surgery app that allows users to play around with digital imaging, and so I extended my chin horizontally to my ideal and dream chin projection. I also took a Qtip and placed it on my lips straight down and then measured the space from where the Qtip drops down to where my chin is at now, and it seems that I am 10 more mm’s away from having the chin in the photoshopped picture. But remember, the current chin implant now gave me 5mm’s, so technically if it’s taken out I would need a total of 15mm’s to achieve my ideal projection. I wish I would of known all this prior because it looks like all the money I spent on this current implant is now going to go down the drain as I am not even half satisfied and just keep dre aming about the chin on the right. I came across your site, and I guess my question to you is that with all that said, how can we go about getting me to the projection I want? Would I need both a genioplasty and implant together? Because I know the biggest implant made is only a 10mm. I just want to do it right this time so I never have to deal with it again.
A: Given that you have a chin implant already in place, it may be best to do a sliding genioplasty for your chin implant revision. (technically chin augmentation revision) The chin implant would stay on the front edge of it, so you still get value of having done the prior procedure, and move the chin forward 8 to 10mms. Otherwise, you would have to have a custom chin implant made to cover the total 15mms horizontal projection desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been reconsidering a sliding genioplasty procedure recently due to the great deficiency my chin has. As I stated in my last email, I am on Remicade and there is a good chance I will still be on that medication when then time comes for the procedure. Does it concern you doing a sliding genioplasty procedure while I am on this medicine? I assume healing may take longer. You have also mentioned that a sliding genioplasty with a chin implant overlay may be necessary. Will this have any negative effect on healing or increase the risk of infection?
A: I have operated on numerous patients who have been on Remicade for Crohn’s disease and I have not seen any healing problems. Such surgeries have been much bigger in surface area trauma and operative times than a sliding genioplasty. The face is uniquely well vascularized and unless there is direct impairment of the blood supply through prior radiation it will not inhibit healing difficulties. The orthopedic literature supports that major bone surgery and joint replacements can heal uneventfully with patients on this medication.
That being said, it is important to work around the dosing of the medication to reduce any risk of adverse healing. Given that Remicade is a TNF blocker and is done by infusion, it would be important to do the surgery about 3 to 4 weeks after the last infusion. This is will than allow a few weeks before the next infusion. With such an approach for a sliding genioplasty I do not envision any difficulty with healing or a prolonged recovery time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am asking an identical array of questions of different surgeons both to become more knowledgeable on the topic as well as making a decision on choosing a surgeon. If you were to undergo sliding genioplasty, which five top surgeons would you choose based on experience and reputation.
A: This is an excellent question and I wish I had a similarly good answer for you. There are many surgeons of different specialities that perform sliding genioplasty but who would be ‘top five’ would escape me. Since I have never seen another surgeon actually perform this procedure other than myself (and that was decades ago in my training), all that I have to go on is whom writes clinically and scientifically about the procedure. And because it is an historic maxillofacial procedure of which there is little new, few surgeons today publish on this procedure. Thus creditable knowledge of who performs a sliding genioplasty technically well I do not know. That does not mean they do not exist, as obviously they do, but I could not honestly give you a list based on useful knowledge of them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I can not figure out what my face needs to look better. I’d really appreciate you taking your time for this. I have been given different surgery options from doctors here in Australia. However my opinion is that the best doctors are located in America, especially for facial surgery. It has been recommended to me that I have cheek implants, buccal lipectomy and a chin implant. But I want to know your opinion since you are regarded as one of the best surgeons in the world for facial reshaping surgery.
A: In looking at your pictures, your facial reshaping/restructuring goal would be to shorten your longer face and provide some more central projection. You have a more flat paranasal/midface and thus you have to be careful with how you change things to not look worse. I would recommend the following:
1) Chin augmentation but by sliding genioplasty as your chin needs to come forward but should become vertically shorter not longer. (implants tend to make the chin longer or at least neutral in vertical length)
2) Malar/Submalar implant augmentation with emphasis on providing with anterior projection not so much width
3) Avoid a buccal lipectomy. That would be one of the worst things you can do to a face that already lacks projection and could easily end up looking gaunt.
4) Paranasal augmentation to build out the base of the nose and the maxilla. This complements what the dimensional changes of the cheeks and chin and avoids ‘leaving the area between the two behind’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been self conscious about my deficient chin my whole life. If I so much as look down, I develop a double chin despite being 5’7″ and weighing only 114 pounds. I used to diet often thinking that this would decrease the roundness/fullness of my face but it wasn’t until recently that I realized it is really the lower 1/3 of my face and its overall deficiency that is causing my face to look round and short.
As you can see, I have a very horizontally as well as vertically short chin. The reason I would like the sliding genioplasty vs. a chin implant is to add vertical length to my face as I feel its shortness makes me look younger than I am and also meek/shy which decreases my confidence in my daily interactions with others.
I’ve done the research on sliding genioplasty vs. chin implant, and one of the questions I have is: If I would like a little extra width added to my actual chin (You can tell in the pictures, especially the one head-on picture, that it is not only short vertically and horizontally, but it is narrow), I have read that only an implant can widen at this area, and that a genioplasty by nature of cutting the bone and advancing it will actually serve to further decrease the width of the chin. Is this true? I would like to decrease the odds of this happening if at all, although perhaps adding width to the chin would not even be as beneficial as I think given my facial size in general and would throw everything out of line aesthetically?
In addition, I have read that only a sliding genioplasty can add vertical height to the chin in addition to horizontal projection, but in other more recent publications I have read that there are new implants manufactured now that can be tailored to the patient and add vertical height as well. Would this be an option for me as it is more cost effective or is sliding genioplasty exclusively the way to go given my individual anatomy?
I am anxious to hear back from you, and thank you so much for taking the time to review my pictures!
A: Many of your perceptions about chin augmentation surgery are correct as it relates to the differences between a sliding genioplasty and a chin implant. Historically, it was true that only a sliding genioplasty could add vertical length to the chin but that is no longer true. There are new performed vertically lengthening chin implants (actually they move the chin position out at a 45 degree angle thus adding both length, projection and width) and custom implants can be made from the patient’s 3D CT for any amount of differing chin dimensional changes.
While a one-piece sliding genioplasty particularly if it adds vertical length can make the chin more narrow, that can be solved by modifying the bone That can be managed by doing a midline split/expansion genioplasty technique and widening the bone as it comes forward and down.
As you can see there are a number of ways to accomplish what you are after for our chin. But the first place to start is to precisely determine what exact chin dimensional changes you need. I will have to do some computer imaging but my initial guess is that about 5mms forward and 5mms vertically longer would be about right. I doubt if your chin should be made any wider as you want to get away from a round and short look and even a slightly more narrow chin in and of itself makes the face look longer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I am a female with a recessive lower chin and a minimal jawline. I have had orthognathic surgery twice now, which has improved my teeth but not the balance of my face. I still have a very convex facial profile with an extremely long vertical jaw angle. Here are some images of my face. I hope these will help you to assess my situation. My last surgery was 11 months ago in which my upper and lower jaw were brought forward to correct an overbite and an open bite. I do feel that my upper jaw (between nose and upper lip) is more elongated than before. As you will see from the photos it is difficult for me to close my lips. I realize that this cannot probably be fixed, however I would like my face to look less long and narrow and my jaw line more defined. My jaw is rather vertical in angle. Any advice very much appreciated.
A: The forward positioning of the maxillomandibular complex has placed a strain on your lip closure as this was not the bony relationship that your lips were ‘designed’ to function over. Along with the upper lip lengthening, these are not rare changes that occur with such maxillomandbular forward movements. In addition, loss of the jaw angle can occur with sagittal split ramus osteotomies (SSRO) of the mandible particularly when the lower jaw moves forward. This can be accentuated in females who may already have a thin and slightly high vertical has angle position initially.
The way to make your face look less vertically long and not so narrow is through a combined sliding genioplasty and jaw angle implants. Small vertically lengthening jaw angle implants (7mm vertical length and 3 to 5mms width) will create more defined jaw angles but not over power the upper face. A sliding genioplasty of the movements of 3mms forward and 6mms vertical reduction would shorten the chin length and also help push up the soft tissue chin pad. This may provide some potential benefit also to reducing the lip strain through a better lower lip position at rest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to hear your expert opinion on whether a chin implant or a sliding genioplasty or some other thing is more appropriate for my jaw. I have attached pictures from 3 angles of my lower jaw, at a default, relaxed face. Notice my big jowls and rounded face. I have been told (by a few oral/maxillofacial surgeons) that a sliding genioplasty would probably be better than a chin implant because, as one surgeon put it,….an implant usually doesn’t create the angles I would need for the roundness to soften up a bit and for significant loose skin to pull. I don’t mind a slightly round face, I just don’t want to look like a balloon on the lower half of my face.
In your experience, how true is this???
A: A properly designed chin implant can create more angles than than a sliding genioplasty. A sliding genioplasty brings the chin forward but will make it more narrow in doing so. That is fine if that is the frontal change that you want….which usually works well for a female. Most males want a more square chin as it comes forward with a genioplasty which will not create that effect unless the bone is split and widened. But in doing so there will be a dip behind the chin in the jawline. Many bone-based facial surgeons often know how to do one chin approach (sliding genioplasty) but often do not have much experience with the array of chin implants, preformed and custom, that are currently available. Both implants and a sliding genioplasty are effective chin augmentation operations but their effects can be dimensionally different. It becomes imperative to know what each of them can aesthetically do and then apply it to the aesthetic needs of the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this grinding type noise when I open my jaw on my right side. I have had orthodontic treatment years ago and have a underdeveloped lower jaw. I consulted my orthodontist about the grinding noise possibly being linked to my underdeveloped lower mandible. He told me that my jaws are lined up correctly and I should do nothing about this grinding noise. At the beginning if my orthodontic treatment a lower mandibular advancement was recommended, however I decided at that time that I would just have orthodontic treatment without surgery. After orthodontic treatment I have a clearly recessive jaw with extra skin around my lower jaw area. As a craniofacial and maxillofacial surgeon I would highly consider your opinion in what my next step should be.
A: Many people have asymptomatic grinding noises which emanate from their temporomandibular joints. This is usually caused by the disc in the joint which may catch on opening as the mandibular condyle comes forward. Underdeveloped lower jaws with Class II malocclusions (orthodontically corrected or not) have a greater propensity for these disc noises. But as long as one is having no pain in the TMJs or any difficulty with opening, there is no treatment indicated. For the recessive jaw and loose skin around it, this can be aesthetically addressed by either a sliding genioplasty or a chin implant. Either approach has certain advantages and disadvantages that must be assessed based on each person’s anatomy and aesthetic desires. The first place to make this determination would require an assessment of pictures from the side and front views.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 26 years old female. I had a chin implant surgery along with a rhinoplasty three years ago. I was happy with the surgery results until I started to see how I looked in pictures. I think that my face looks too long, and in some pictures it looks really especially when I smile. I also dislike my gummy smile, though I can hide it when I try not to rise my lips. I don’t know what the problem is. What would be the most recommended procedure for me? I would like to look more feminine and balanced. Could a smaller chin implant make my face more balanced? are there any risks involved?
Could cheek fillers or implants help? Or should I also consider the possibility of orthognathic surgery, in case the camouflage would yield very limited results..
What other procedure would you recommend for me? The upper part is me before the surgery, and the lower part is me after the surgery. And I also attached my X ray.
A: While both your rhinoplasty and chin implant augmentation produced good results, I see the crux of your facial concerns with the chin area. It is a very large implant which was needed but is also the source of your facial imbalance.
You initially have a very retrusive chin due to an underdeveloped lower jaw. When the chin is so short due to an underdeveloped ramus of the back part of the lower jaw, it is also vertically long anteriorly as the chin rotates downward. With a chin implant used for the augmentation, it does bring it forward but also actually makes the chin vertically longer and with a much deeper labiomental fold. A better chin augmentation would have been a sliding genioplasty. This would also bring the chin forward but it vertically shortens the chin and makes it more narrow, both changes which are more feminine.
Thus I would recommend that you replace your large chin implant with a sliding genioplasty that does not create as much horizontal projection but also vertically shortens it as well. It will also make the chin more of a triangular shape rather than have an obvious square shape to it that it has now from the outline of the implant. You may also consider adding small cheek implants to bring a little highlight to the cheek area, which with the genioplasty, would give your face more of a feminine heart shape to it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am one month post-op from a v-line jaw reduction and sliding genioplasty. Although I am well aware that I am not at my final result due to swelling, observing through my x-rays I can confirm that my chin has actually increased in vertical length when I desperately wanted the opposite. My surgeon is unfortunately non-responsive. My question is, is there any way I could undergo a revision sometime in the next month since the detached part of my chin that is secured with screws is entirely the length of bone that I would like to have removed? I have linked my post-op x-ray with a photoshopped x-ray of what my desired results are to clarify what I am trying to express. Thank you so much for your time!
A: It appears that you have had a set back sliding genioplasty from your x-ray. The severe angle of the bone cut makes vertical lengthening occur when the downfractured bone segment is slide backward. To effect that degree of vertical shortening that you want, you would take out a wedge of bone from above the cut and bring the lower segment up to it. You can not just remove the bottom segment because the muscular and soft tissue attachments to the chin bone would be lost resulting in significant chin and neck soft tissue sag. Given that you have not had any bony healing from your prior sliding genioplasty, you should have such a revision in the next few weeks or month.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper jaw surgery and a sliding genioplasty done four years ago when I was 18 years old. I have never been happy with the results on my chin and would like it reversed, is this possible? The surgery left indention’s on the sides of my chin and a upturned appearance to the chin.
A: A Sliding genioplasty can be reversed in the same fashion as it was done originally…the bone is cut and moved back to its original position. I suspect based on your description of the chin issues (notch deformities on the distal ends of the cuts and an upturned chin) that the angle of the genioplasty cuts was too steep. This moves the chin as much upward as it brings it forward and leaves a v-shaped notch on the lower edge of the jawline where the chin bone moved forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My question is what should type of chin procedure do I need to get the best possible aesthetic result. I had double jaw surgery six weeks ago, and also a medium size silicone implant placed intraorally and fixed with 2 screws. I think most of the swelling is gone now. I’m noticing that my mentalis muscle is acting up again, especially at the bottom of my chin. I thought the implant as well as reduction of my vertical maxillary excess and lower jaw advancement would have resolved the mentalis strain completely. The bumpy appearance is much better than before I had the implant, but I’m unhappy with any dimpling, and am worried that it will return in full force eventually. I also think my chin implant projects too far forward (for a female) and it looks too high. I would ideally like my chin to taper to a slight V in the frontal view rather than the flat U I have now. I also noticed my lower lip looks really asymmetric post-surgery, wondering if it has to do with the implant? What would be the best course of action? Reposition or replace the implant? Fillers? Botox the mentalis? Sliding genioplasty? Thank you for your time and consideration.
A: While an implant offers the simplest approach to chin augmentation, it is usually not ideal in the face of a functional mentalis strain and can produce an aesthetically undesireable widening in a female. From your profile picture, I would agree that it seems too highly positioned which can also place a strain on the mentalis muscle.
For substantative improvement, it now appears that the implant should be replaced by a sliding genioplasty whose dimensional movements I can not say just based in these pictures. That would not only improve the mentalis muscle position but the chin could be narrowed in the frontal view with a v-line reduction technique as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read literature online that (if I comprehended it appropriately) that a sliding genioplasty can relapse. Meaning, the chin advancement goes back to the original placement over time. Is this really true? Also, can bone resorption and/or bone remodeling in the long run take away from the aesthetic appearance achieved from the initial sliding genioplasty procedure? I thought the results of this procedure were supposed to be permanent. Let me know what your thoughts are.
A: If a sliding genioplasty is rigidly plated into position, theres is zero chance of relapse. You are referencing old chin fixation techniques that only used wire fixation which are far less stable. While I doubt they could even then relapse back to the their original position, they were less secure the further the chin was advanced.
In extreme or large amounts of chin advancement (10mms or greater), bony remodeling may account for a negligible amount of reshaping over the pogonion area of about 1mm. This is not aesthetically noticeable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will a sliding genioplasty improve my lip incompetence? I would like my chin moved forward. My chin also looks long when I force my lower lip up to close my mouth. Would a slight vertical reduction be beneficial as well? First picture shows my lip incompetence (my teeth are touching) and second picture shows the increase in vertical length. Thanks for your time.
A: Besides a change in the horizontal position of the chin, you are describing what a sliding genioplasty can do really well…vertically shorten the chin and improve lip competence. By bring the chin forward and making it vertically shorter, the position of the mentalis muscle is changed and an upward push occurs on the lower lip. Together this produces improvement or complete elimination of any non-iatrogenic lower lip incompetence problem. It is now just a question of the different millimeters of movement, how much horizontal movement (probably 4 to 5mms) and how much vertically shorter (probably 3mms) in just looking at your profile picture.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 25 year old male who currently has braces. Wondering if I should have BSSO mandibular advancement or sliding genioplasty. My jaw is strong but my chin is weak especially when biting.
A: The answer to the choice between a mandibular advancement or a sliding genioplasty to improve your profile is literally ‘between your teeth’. Since you are in braces, the key question is what is your bite relationship and what does your orthodontist to tell you? Is your bite correctable by orthodontics alone or is the discrepancy between your upper and lower teeth significant enough that the lower jaw needs to be brought forward to put your bite together properly and, if so, how much does it need to be moved forward.
There are three possibilities. #1 Your bite is going to be corrected by orthodontics alone and then a sliding genioplasty is needed. #2 Your bite is far enough apart that the lower jaw need to come forward significantly (7 to 10mms) and the profile will be corrected completely by that movement alone. #3 Your bite correction requires a small amount of mandibular advancement and a small sliding genioplasty will be needed as well.
Regardless of the type of mandibular or chin movement needed, I have attached a prediction of the type of change needed for normalizing your facial profile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was interested in a chin reduction surgery, perhaps rhinoplasty (although I really don’t mind my nose). I am very comfortable with my appearance, and don’t mind it much although I find my chin to be too large! I think I would be much more attractive and feminine if I had a smaller, less gaunt/obvious chin. I was wondering if you could possible let me know if I would be a good candidate? I know most doctors suggest a traditional ‘almond’ shape, but I don’t mind my jaw square-ness, I just wish my face were shorter. Thank you, I can’t wait to hear your reply!
A: Your chin reduction request is a bit uncommon as what you have is a horizontally short chin that is vertically long because of its retrusive position. This type of chin reduction would actually be performed by a sliding genioplasty technique where the vertically long but horizontally short chin bone is cut at an angle and moved forward. (with a wedge of chin bone removed in the process) I have attached some imaging to illustrate that type of change. What actually happens is that as the chin bone comes forward it is vertically shortened as it is horizontally advanced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had rhinoplasty, Medpor jaw angle implants (11mm projection) and silicone chin implant (medium 7mm). But I want a stronger look that is more masculine. I also want cheek augmentation and I want a stronger chin. But the biggest chin implant I can find only gives 8mm horizontal projection so I’m considering a sliding genioplasy to have both horizontal and vertical augmentation. For the cheek implants iIm considering Design M Malar Implants from Medpor, I think they’re more anatomic than silicone ones, and also Medpor ones augment from zygomatic arch to the cheek bone which I think will give a stronger and masculine look. I would like to know which size would you recommend me to use. (4.5mm or 7mm) so they would look proportional to my jaw angle implants (11mm) I read in the internet that when you use facial implants, you have to consider the soft tissue augmentation that is different from the size of the implant… for example if you have a chin implant with 10mm projection…you’ll end up only with 7mm in soft tissue projection. So if I have cheek implants size of 4.5mm I’ll end up with 3mm augmentation, but if I have the 7mm ones,, I’ll end up with 4.9mm, So i don’t know which ones to use. I read in your blog that when it comes to cheek augmentation you should not over do this specific part because you will look unnatural. I definitely don’t want that. But also I have read that the cheek or zygomatic bone should be bigger than jaw angle.
A: I would take exception with your supposition that there is not a 1:1 correlation with the translation of implant thickness to how much change is seen on the outside. When it comes to any form of jawline augmentation, it is pretty much a 1:1 correlation. In the cheeks it is most commonly a 0.8:1 ratio. However the thickness of the soft tissues in any patient is so variable that no absolute implant size to external change seen can be generalized. Thus I would always assume it is a 1:1 relationship through the skeletal structure of the face. This would be true in my opinion given your relatively thin face.
I would also point out that a little bit in the cheeks goes a long way so I would be careful about going too big here. It is very easy to end up with cheek implants that are too big. Thus, I would lean towards the 4.5mm implants as opposed to the 7mm thick cheek implants.
Lastly, you can certainly do a sliding genioplasty using/keeping the existing chin implant in place getting the dual benefits of both techniques. However be aware as the slidinjg genioplasty moves forward and down there will be a slimming.narrowing effect on the chin. Thus if you want to end with a more square chin look than you have now, the chin implant should be switched to a square design or even a more square one and not a rounder anatomic style.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Which is better for me, jaw advancement or a sliding genioplasty. I think my whole lower jaw is short and needs to be brought forward. I have attached some view pictures of my ideal result and an x-ray of my jaws from the side view. Can you tell me what I really need to give my face/lower jaw a better profile?
A: What you have is a classic Class malocclusion/dental relationship which accounts for the retrognathic lower facial profile and the associated soft tissues effects. A sagittal split mandibular osteotomy would be the ideal procedure which requires some preoperative orthodontic preparation. (as the amount of forward jaw movement is completely controlled by how the teeth fit together afterwards. Whether the amount of forward jaw movement would create the profile change you have shown would have to be determined by preoperative cephalometric tracings.It is possible that a small sliding genioplasty movement may be needed with it as well. But this can not yet be determined until the orthodontics have you prepared for surgery.
If orthodontics are not in the plan, then an isolated sliding genioplasty would need to be done to create the bony chin and profile change. Moving the whole mandible is skeletally better (as it moves the teeth and lower lip forward as well but that completely depends on orthodontic preparation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had a bilateral sagittal split ramus mandibular osteotomy with a sliding genioplasty. My bottom lip (and perhaps top) have thinned considerably. It seems the bottom lip flips in somewhat. It was always very full and pouty. Can something be done? In addition, my jaw angles used to be much more prominent and I had a longer ramus. What can be done? Will reversing the genioplasty help?
A: Reversing the genioplasty is not the solution for an inward inversion of the lower lip after the procedure. That is caused by disruption of the origin of the mentalis muscle on the bone and it being resutured back together. This can be a source of lower lip tightness, lower lip thinning, and some inward inversion/contracture of the lower lip. Unless you terribly dislike the position of the chin, moving the chin back is not going to solve these soft tissue problems. Rather some soft tissue augmentation is a better approach. This could include the placement of a dermal-fat graft below the vestibule in the lower lip after it is released. (all done through your existing intraoral incision) Fat injections can also be done at the same time into the lips. The take of fat injections is variable but that of the dermal-fat graft assured.
Many BSSO procedures change the shape of the jaw angles, often losing their distinct shape. They often appear less pronounced and higher afterwards when the bone has healed. In some patients, jaw angle implants can restore a more distinct shape and the addition of a little angular width as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am scheduled to have a sliding genioplasty next month and I just wanted to clarify some things. Is there some sort of guarantee I get that this procedure it would improve or completelyy resolve my sleep apnea? Otherwise I don’t see any other benefit other than the profile improvement which would not be worth the surgery risk.
A: The simple general answer to your question is no. There are no guarantees in plastic surgery of any specific outcome. Any surgery is an educated guess that doing a certain maneuver will cause a specific effect. In some surgeries, experience may show that a certain outcome is very likely if not highly predictable. In other types of plastic surgery, the outcomes are less predictable and may, in some cases, be more hopeful than completely predictable.
When it comes to a sliding genioplasty, both sides of these potential outcomes are seen. It is a predictable fact that moving the chin bone forward will change one’s profile and give a stronger chin appearance. Once can debate whether the chin changes net a patient’s expectation but there is no debating that the chin position will change. When performing a sliding genioplasty to help improve sleep apnea, the results are less assured. In theory, when moving the chin forward the tongue is likewise brought forward somewhat due to the attachment genioglossus muscle between the tongue and the back of the chin bone. This is actually the basis of the historic genioglossus advancement procedure done for sleep apnea when a sliding genioplasty is not being performed. To be successful for sleep apnea improvement, the sliding genioplasty movement must usually be significant (greater than 10mms) and one should have a very short or horizontally deficient chin. (indicating there may be posterior tongue prolapse) Often a lateral cephalometric x-rays will show the position of the base of the tongue to the posterior pharyngeal wall with a narrow airway space. But because the sliding genioplasty moves the front position of the tongue more forward than the back (closer to the point of pull), the amount of chin bone movement does not translate in a 1:1 ratio to what occurs further back at the base of the tongue and the posterior airway opening. This is the anatomic variable in whether a sliding genioplasty will help improve sleep apnea symptoms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I definitely want to remove my acne scars, but other than that, I’ve been given so many different suggestions, I’m not even sure anymore. For the acne scar laser resurfacing, I was told my skin type has a high chance of pigmentation. What are safe options? I do want a rhinoplasty, but I want it to be very subtle, and I’m mainly interested in fixing the tip that sort of goes down like a beak. How is this usually corrected? Also, you mentioned that it appears my buccal lobe was removed. Does this mean the maximum amount was taken out? I am now 2.5 weeks post op. Do you think my final results will give me the skeletonized appearance I desire? I still feel 2 grape sized bumps, hard as rock, when I push down on my cheeks.
A: What would structurally benefit your face is not a mystery and is very straightforward…it lies with your nose and chin. Your chin is very deficient, by at least 9mms, and is one feature that will keep your face from ever having a very defined and angular appearance., By using a sliding genioplasty to bring it forward it will improve your facial profile and help create a more defined appearance in the front view.
You have a very classic ethnic nose with a broad flat tip that has little support and no projection, hence a rounded tip that droops down. An open tip rhinoplasty will reshape the tip and give it a better profile and a more narrow appearance in the frontal view. You would also need some upper dorsal/radix augmentation.
Fractional laser resurfacing is the only type of acne laser resurfacing that you should have as this has a very low risk of any hypopigmentation problems. It will take more than one treatment and the best result you can hope for is about a 50% improvement in the appearance of your facial acne scarring.
It takes a full 3 months for the buccal space where the fat pads were removed to become soft and not feel as hard lumps, this is perfectly normal to feel what you are feeling at just 3 weeks after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty, sliding genioplasty and a lip lift. I was born with a unilateral cleft lip and I want my face to be more symmetric. What procedures do you think should be done?I have had one rhinoplasty and I have an L shaped implant. I would like for my nose to be more narrow and symmetrical. With the lip lift I want my lip to be about 15mm or shorter. I have a chin implant, but I think with the genioplasty it will make my chin balance out with the rest of my face.
A: I have done some computer imaging done on your chin, jaw angles, lip and nose. I think it is fairly clear that your chin is fairly short even with the implant in place. This shows that the jaw is rotated up and back (short) and is why the jaw angles are high. A sliding genioplasty (possibly leaving the chin implant in place and moving it with the bone) may be needed to get the 12 to 15mms forward movement you need. Moderate jaw angle implants in the back will help fill give them some more definition. You don’t need your upper lip lifted by 15mms, that would be too much. Something like 5 to 7mms would be more appropriate. The question here is whether it should be done by a subnasal lip lift (lift only the central portion) or a vermilion advancement which moves the whole lip up. (probably better) The nose is challenging because of your very thick skin and the naturally thicker tip skin that many cleft patients have. To make a real difference, the implant ideally needs to be replaced by an L-shaped rib graft so you can get more of a push/lift on the skin and a sharper tip point. The implant just makes it rounder and still short.
The imaging done is to just figure out of these procedures are beneficial. The fine details of it and the degree of changes is an issue up for discussion.
Dr. Barry Eppley
Indianapolis, Indiana