Your Questions
Your Questions
Q: Dr. Eppley, I feel that I have a slightly vertically long chin and a prominent jawline. My chin lengthens when I smile. From my profile however, my chin does not seem to have much projection and is slightly receding. A year ago I had a jawline and chin contour but I feel my results are minimal at best. I am consulting with you because I am looking for an expert opinion and what realistically can be done.
A: Often in chins that are retrusive, they are also vertically long because of the backward rotation of the entire mandible. (jaw) This would account for your chin lengthening when you smile but yet it looking too short in profile. I don’t know what type of chin and jawline contouring you had done but I would think your issue is improveable by a ‘redistribution’ issue as opposed to a completely reduction approach. (taking away bone with this nine shape would likely produce no substantial change in its appearance) It would seem that if your chin bone is brought forward and vertically shortened at the same time (angled sliding genioplasty) that would be the correct bony reshaping needed to address what the problem really is. I would envision no more than a 5mm chin advancement but a 5mm vertical shortening as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am about two months after double jaw surgery and sliding genioplasty to correct an open bite and weak chin. Everything is healing nicely, however since day one of my genioplasty, I have noticed that when I raise my lower lip or close my mouth, there is a “shelf” that forms from the mentalis muscle pushing up. It looks like a very deep labiomental fold, however it protrudes enough for me to be able to literally grab onto the muscle that is sticking out. This has been causing me to be tremendously depressed to the point where I’ve gone back to my surgeon and requested a revearsal of the genioplasty. I’ve been hearing about ptosis problems associated with chin augmentations, however mine seems to be the opposite. It looks fine with my mouth is open, however when closed, the muscle seems to be contracted too much and pushing out of my face. All of the doctors I’ve seen at my surgeon’s office seem to think that it will resolve with time, and that the incisions need to mature before the muscles can fully relax. However, it hasn’t shown any improvement. I was told if it doesn’t resolve by April, then it can be addressed, although I hate to wait that long. What I want to know is, what exactly is causing this, what is it, and by which method can it be fixed?
A: In a sliding genioplasty, the chin bone is brought forward and brings with it all of the attached soft tissue. Depending upon the angle of the bone cut of the genioplasty, the amount of bony advancement, the shape of the chin soft tissue pad before surgery, and how the mentalis muscle was sewn back will all influence how the chin soft tissue pad now looks and moves. What you are describing and demonstrating in your picture is a dynamic muscular deformity of the chin pad. (a roll becomes present when smiling, OK at rest) What I would do is first have some Botox injections done into this chin roll to determine if this is aesthetically helpful. If it improves with Botox then it becomes a later question of a mentalis muscle release and repositioning. (this also buys you some time without having the chin pad deformity as well ) If it does not improve with Botox injections then the only improvement is going to come from undoing the genioplasty to some degree. The interesting question in this regards is how much did the chin bone move forward and as it vertically shortened at the same time. In larger sliding genioplasty movements, the chin bone may come forward but may also get vertically shorter. This may cause some soft tissue bunching when one smiles as there is now an ‘excess’ of tissue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am debating on a sliding genioplasty vs silicone implant for chin augmentation.. I know that up to 10mms in vertical length can be achieved by a genioplasty, as well as width changes through hydroxyapatite blocks. I would like to get your personal opinion on this. For a male, what would be a normal range of chin length from lowest part of the bottom lip to the end of the chin? What length would the chin need to be for a male in order to warrant a lengthening genioplasty or to declare it unnecessary? I want to add as much size to my face as possible, length and width wise.
A: For chin augmentation, both a sliding genioplasty and an implant can be used to create vertical length for a more profound or dominant chin. However, there is no standard or normal range for how vertically long one’s chin should be. It is more of a ratio to the other vertical facial thirds and how dominant one prefers their lower third of the face. As a general rule in my experience, few patients need the vertical length of the chin increased by as much as 10mm. That would be too long for even many men, particularly when other dimensions of the chin are being added as well.
While a sliding genioplasty is traditionally perceived as being the only method to vertically lengthen the chin, custom designed implants can also be used today. However they may not do it equally well. Because of the limits of the bone cuts of a sliding genioplasty, significant vertical lengthening may look ‘unusual‘ as only the chin of the jawline drops down. In contrast, custom designed implant can vertically lengthen a larger portion or the entire jawline for a more natural blending of the vertical lengthening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a sliding genioplasty a few months and this dent has appeared between my lip and chin that was not there before the surgery. Why has this dent occured and can it be fixed. While I like my new chin position, I do not like this dent and want it fixed if possible.
A: A sliding genioplasty moves the chin bone forward but does not change what lies above it. That dent is the labiomental fold/sulcus which is the fixed attachment of the superior mentalis muscle to the bone. It may have become more prominent after surgery due to the chin advancement and/or scar tissue or a tightly restored mental is muscle attachment. I have seen this numerous times after chin advancement procedures particularly sliding genioplasties. It can be improved/fixed by either an intraoral release alone or combined with a dermal-fat graft after the release to prevent it from becoming re-attached.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of a sliding genioplasty revision. I had sliding genioplasty done which left me with a defect on the right side. The surgeon who performed the initial operation was going to take bone from jaw to fill the defect, but I was thinking it would turn out badly considering how bad it looked directly after the procedure. That was more than 10 years ago. A second surgeon I consulted stated he would use artificial filler to patch the defect and a very small implant if I wanted a more triangular “pixie-like” look to the chin. I definitely don’t want my jaw any wider. In fact I’d like it symmetric and less squared off on the sides. I’m just looking into my options at this point. I had so much trouble after the first operation with permanent anesthesia of the lower gum and my lip being slightly crooked. Scared it might end up worse.
A: What is have is a rather classic sliding genioplasty revsion problem. When the chin bone is brought forward, it narrows the chin and can leave at the bony tails an indentation or step-off at the back edge of the genioplasty. Whether this occurs depends on how far the chin bone is brought forward and the angle of the bony cut. Sometimes this lower jaw edge defect can only be felt, in other cases it can be seen as in your case. The two approaches to treat it are to fill in the bony defects, often with hydroxyapatite granules, or with an overlying chin-prejowl implant. But either approach will tend to make your chin somewhat wider. The other approach is to narrow or remove the bony edge by making it more v-shaped or narrow. Such a chin reshaping procedure would not be associated with the issues you had during the initial sliding genioplasty since the bone is not being downfractured.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a chin implant questions/issue. In my opinion, I have a recessed chin and jaw. Eight years ago, I had a large silicone chin implant inserted, and liposuction below my chin. At my consultation, the plastic surgeon asked if I breathed through my mouth, which I realized I do. Ever since then, I have been on a quest to resolve this issue. I have been to an ENT doctor who said my nasal passages checked out fine. But since I feel that my chin implant did not provide me with enough projection (I am 41 years old but one year ago I had a platysmaplasty for loose skin beneath my chin), and my lips still do not close with out mentalis strain, and as I age I feel that my lack of a supportive jaw is not helping, I would really like to take action. Also, I recently discovered that chin implants have been known to cause bone erosion, which frightens me. I had braces as a teenager, and still have a bit of an overbite, but I do not know where that leaves me as far as options to both improve my appearance and breathing functions. I sincerely appreciate your time and thoughtfulness, as this is quite daunting to me.
A: The chin implant issue that you describe is a common one that I hear about. Between your appearance and breathing issues, your description suggests that your lower face/jawline appearance can be improved. With a naturally short lower jaw, a large chin implant that is still inadequate in projection and a residual mentalis strain, this indicates to me that you need a sliding genioplasty for a chin implant replacement. Besides the limitation of chin implant projection (10mms or less), increasing the chin point by an implant will not improve mentalis muscular function nor any lower lip incompetence should it exist. Your existing chin implant may have also developed some settling into the bone. (often erroneously referred to as ‘bone erosion’ which is not harmful) By removing your chin implant and performing a sliding genioplasty you will improve your chin projection, eliminate the mentalis strain, and also improve your neck profile. I would need to see some pictures of your face to verify these statements but your description is not a rare problem that I see with indwelling large chin implants.
As for your breathing issues, nothing you do to the chin will have any impact on your nasal airway exchange.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a sliding genioplasty but want to know how much it can change the shape of the chin? What is the maximum vertical height and horizontal projection I can receive?
A: The maximum chin changes that can be achieved with a sliding genioplasty is based on the thickness of the chin bone, particularly as it relates to increased horizontal projection. You do not want to move the osteotomized chin bone beyond contact with the superior fixed chin bone. In general, that puts the advancement in the 10 to 12mm range which based on your picture seem more than you would need. As for vertical lengthening, the amount that the osteotomy can be opened depends on whether the created gap would need to be grafted. (with an hydroxyapatite block) For openings up to 5 or 6mm, no graft would be needed. But anything beyond that (8 to 10mms) would need to be grafted. Again, that distance seems greater than your picture would indicate that it is needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,Is wisdom teeth removal a prerequisite for an osseous sliding genioplasty? Also, how much does your practice charge for an osseous genioplasty (with hospital fees + anesthesia)?
A: There is no correlation between a sliding genioplasty and wisdom teeth, whether they are removed or not. The chin is located on the front part of the jaw while the wisdom teeth (third molars) is on the back part of the jaw. You may be thinking of a sagittal split ramus osteotomy (back of the jaw osteotomy) where having impacted wisdom teeth out six months before the procedure is needed as the embedded tooth roots may interfere with successful splitting of the bone and plate the screw fixation to hold it together as it heals. In fact, wisdom teeth removal can be done at the same time as a sliding genioplasty if necessary.
A sliding genioplasty is done as a one hour procedure done under general anesthesia in a surgery center not a hospital. The usual total fees are around $6500 for all involved costs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of facial freshaping. I have some issues regarding a long face, and more importantly a long midface. It’s just been seriously bothering me for years to the point where it is causing problems. If you could take a look at these pics and just figure out what is so wrong with it, i would really appreciate it.
A: While I would not disagree that your face is a little long and the guilty component is your midface, there are other facial structural issues that are magnifing that impression. A horizontally short chin and a long nose with an acute nasolabial angle make the midface loo longer than it already. When you combine that with a very skeletonized face (little facial fat), the effect becomes even more so. There really are no true midface shortening procedures other than a maxillary impaction which is only used for vertical maxillary excess that has a gumkmy smile. (which does not apply to you) But what you can do is change some of the other factors that are accentuating the midface elongation effect. This includes a sliding genioplasty to bring the chin forward, a rhinoplasty to rotate the tip and decrease its length and submalar cheek augmentation to procide some more width to the midface. Together, these facial structural procedures can help shorten a long midface appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an intraoral large silicone chin implant placed about nine years ago and have had a lot of chin implant complications. am 31 years old now and since the beginning I got into a cycle of pain from chin swelling followed by tightness, numbness and itching sensations. Rare were the moments where my chin wasn´t swollen and pain free. The itching is basically in my right cheek. Four years ago I had a fibrosis inside this right part of my face and the doctor thought it was due to the tip of the implant so he had cut the cheek from the outside and cut the tip of the implant filling the hole left from the fibrosis with body fat. The appearance from the right cheek didn´t improve much and from then on I had to carry a scar from the procedure. About a year ago I had a fistula in the right gum that bleeds weekly. I´m terrified about the implant removal procedure been performed by the same doctor, the pain not going away due to eventual permanent nerve damage and bad looking chin appearance after removal. Do you know how to solve this by eliminating the pain and also leaving me with a good looking chin?
A: Chin implant complications of this magnitude are rare. I am not sure why you have such symptoms of itching and chronic pain but this long sequence of events suggests that the implant should be removed and your chin augmentation done with a sliding genioplasty. Moving the chin bone would eliminate any potential concerns about a foreign body in your chin and all the issues that have accompanied it. I would need to see some pictures of your chin for your further assessment but this does not sound like an implant salvageable situation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am very sorry to disturb you, I live in a remote area of Russia, and my grandson was born with craniofacial distortions of his face and skull. My friend found your contact details in the Internet. I have a few questions to you:
1) Is it possible to enhance at the same time (by one surgery) my grandson’s forehead and back of his head? They are both too flat and the maximum distance between his eyebrow line and the back of the head is 14.7 cm only. By how much is it possible to make this length longer?
2) What should it be done with his medium face? Will it be the treatment by implants, or it is possible to put there human grease/fat?
3) What else could you recommend on him ? We know that he also needs the surgeries on his jaws.
4) How much will it cost us to get the above mentioned treatments ( 1) and 2) points) at your clinic in the USA?
Thank you so much for your reply.
A: Thank you for your inquiry. In looking at your grandson’s pictures, it is clear that he was born with some form of craniofacial deformity, most likely one of the craniosynostoses. (Crouzon’s etc) It also appears based on the scars on his forehead that he may have had some initial efforts at craniofacial surgery when he was younger.
While you did not state his age, he appears to be a mid-teenager at least. I will separate his craniofacial concerns for this discussion into cranial (skull/forehead) and face.
From a skull standpoint he has a short front to back distance typical of many congenital craniosynostoses. He is shorter in the back than in the front in my assessment. The back (occiput) can be augmented significantly (up to 2 cms.) and the forehead smoothed out for a better contour. The most relevant issue here is where is his previous coronal (scalp) incision as that will determine how to approach is skull augmentation reshaping.
From a face standpoint there are two directions to go. Ideally he needs pre- and postsurgical orthodontics and a LeFort I midface advancement with a sliding chin genioplasty. The key there is orthodontic preparation. If this is not possible, the second approach is to camouflage the bony deformities by a combination of orbital, cheek and paranasal implants combined with a sliding genioplasty. (see attached imaging) That could be done at the same time as skull augmentation.
The key in any complex craniofacial problem in a mid- to late adolescent is to identify those craniofacial surgery procedures that are most practical to do that provide the greatest physical and psychological change for the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, 1. Am interested in an overall approach to address my weak jawline/chin and nasolabial folds. I had a smaller chin implant over 20 years ago, but I am certain that advances since that time could provide me with a better overall result.
A: I have received your pictures and done some initial imaging predictions. Knowing that you have a chin implant in place with your high jaw angles indicates how short your lower jaw really is. Substantial improvement can come by changing all dimensions of the jawline, not just the horizontal position of the chin. There are two fundamental approaches. A sliding genioplasty combined with an extended chin-jawline implant overlay with vertical lengthening jaw angle implants is one option. The second choice would be a custom total wrap around jawline implant made from a computer-generated design off of a 3D CT scan. There are advantage and disadvantages with either method. Either approach takes it way beyond what the simplistic approach of ‘chin augmentation’ would achieve by looking at a complete jawline enhancement. As you know, your lower jaw issue is not just a simple isolated chin deficiency.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about genioplasty, I hope you can help me. Is it normal to feel the screws after a genioplasty? (I refer to touch the chin with the fingers) If you can feel the screws is it a bad thing? Can screws create volume on my chin? In this second genioplasty the chin was vertically. (5mm) This is my 7th day after surgery
but I’m worried because just touching my chin, I can feel the screws. Does that mean my surgeon did a bad job? Any solution for this? In the first genioplasty never had this experience but that surgery was just a horizontal cut.
A: The only circumstances in which screws after a genioplasty can be felt is if there were placed in a lag screw fashion where the screwheads would be on the edge of the advanced chin bone in a horizontal cutr or if the chinb was vertically lengthened and the inferior location of the plate and screws may be at the bottom edge of the bone. The fact that you feel them is harmless. They can not create more chin volume per se. It just means the location of the plates and screws may be palpable, that is not harmful or dangerous. After it heals (one year) you can have them removed if it continues to be a concern for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wondering if a jaw surgery can correct my facial features. My jaw appears to start almost directly from my ears and angle downwards instead of forwards like you see in pretty people. My face is long and narrows towards a tiny recessed chin. Actually, the lower third of my face angles backwards. My chin is slightly bumpy with my mouth closed, and very bumpy when I stick my bottom lips out. I have no bite problems since I’ve had braces when I was a teen (spacers for crowded teeth and a hyrax to expand my upper palete, but no headgear or tooth removal) I’ve heard that orthodontics can lengthen the face and lead to a recessed chin and humped nose over time. I’m not sure if my braces caused my facial problems or if it is genetic because my dad also has similar facial features and also had braces when he was younger. Is there a jaw surgery, or perhaps multiple surgeries that can fix the angle of my jaw and also my recessed features?
A: Your pictures show a classic case of a short lower jaw with a small chin and a high jaw angle. Your chin also shows a mentalis muscle strain which is why it is bumpy. (muscle fasciculations) Since you have no occlusal disharmony (bite problems), jaw surgery (moving the entire jaw forward) can not be done. Even if your jaw was moved forward the high jaw angles would not be changed. (the chin would be corrected however) The proper treatment for you now is a combined sliding genioplasty (moving the chin bone forward) combined with vertical lengthening jaw angle implants. This combination puts the shape of the lower jaw in better balance. (chin comes forward, jaw angles drop down)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, At the moment, I am at a complete loss of what to do about my profile. I have had so many consultations now and have advice ranging from ‘do nothing’ to ‘have a neck lift, fat removal and chin implant at the same time’. I need to do something as it’s making me very self conscious and I hate seeing photos of myself from the side.
My problem is that I am only 27 and am apparently not a candidate for neck liposuction alone because of my bone structure. It has to be explained to me that I have a low hyoid bone that is creating a blunted neck angle so that my neck blends into my chin. My teeth do align so it is not a problem with my bite but I do also have a weak chin.
From my own research it seems like a chin implant might provide me with the illusion of an improved neck angle but my concern is how it will impact my face front on and my smile- lots of reviews seem to say their jaw looks to masculine after a chin implant or that they can no longer show their bottom teeth when smiling. At the moment when I smile I show my bottom teeth, which I like, and my chin points slightly in feminine way. I also have a small indent in my chin when I smile and am unsure if a chin implant would make this worse.
Do you have a recommended approach to this sort of problem? Given my age, I don’t want to risk ruining my face with anything too drastic! I do need to do something though as it’s making me really self conscious.
Thanks in advance for your help. I do wish I was a more straightforward case!
A: Quite frankly you are a very straightforward case. The combination of chin augmentation and neck liposuction is the correct approach. The key to a successful chin augmentation in you is to understand that in the profile view there needs to be both a horizontal and vertical dimensional change and in the front view the chin shape needs to stay a triangular shape and not become too round or full which is more masculine. There are two ways to achieve these chin changes. An implant needs to have some vertical elongation and must be more of a central buton style that has no significant lateral wings to it. The other option is a sliding genioplasty which can be brought forward as well as down. (vertical lengthening) Sliding genioplasties will always keep a narrow chin or make one more narrow as it comes forward because it is a U-shaped that is being brought forward. The indent in your chin, whether the augmentation is done by an implant or an osteotomy, will not change.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I find that my jaw slants downwards and my chin appears too long for my face. My chin is also weak as it does not protrude as far as my lower lip. If possible, I have attached photos and some crude imaging to get your opinion on what you would recommend for me. Thank you.
A: Thank you for sending your pictures. What you are describing and have is the classic steep mandibular plane angle problem. With a short chin many times the jaw angles are high, all which reflect some degree of underdevelopment of the mandible. I can see from your attempts at imaging that you need a sliding genioplasty to move the chin forward but to vertically shorten it (an implant will keep it just as long if not longer) and vertical lengthening jaw angle implants that adds zero width. You are correct by that imaging in that the best way to change a steep mandibular plane angle is to lower the jaw angle and shorten the chin as it comes forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 21 years old and I bit unhappy about my profile…I was thinking about doing something on my chin,nose and ears what would you recommend me. I have sent you some recent pictures of me.
A: In answer to your questions, You would benefit by any three of the procedures that you described.
1) Your ears do stick out the left more than the right. A setback otoplasty would be very effective.
2) Your nose is very ‘juvenile’ in shape with a low dorsum and a soft amorphous round tip. An augmentative rhinoplasty to build up the bridge, give the tip more projection but also narrow it would give your nose a more defined structure.
3) Your chin is short both horizontally and vertically. A sliding genioplasty or a combined horizontal/vertical lengthening chin implant would make your profile more balanced and proportionate for a male.
I have attached some imaging which reflects these proposed changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I undergone a genioplasty 18 months ago where a 5mm medpor implant was inserted through the chin. It improved my profile view and made my face more masculine, but it hated how it looked from the front, making my lower face square while I originally had a V-shape that I liked. The new chin was larger and squarer than my lower dental arch, so it looked weird at different angles. I asked for a revision 6 months ago where my surgeon shaved the wings off and tried to better adapt to my natural asymmetry. Today it still looks weird to me, even though it made me get some of my original features back. The bulging is now more isolated in the front, which is another kind of weird, as a matter of speak. I am now fairly certain I want it out, even if it means losing the profile improvement.
My questions:
– How dangerous is it to remove medpor after 18 months ? I know you wrote it’s only relatively more difficult compared to silastic (my surgeon says the same), but it is my face I have to be really careful with what I do next. Am I facing some loss of tissue/bone/muscle ? Do I risk some sagging (perhaps having reduced the implant’s size first will help in that regard ?) ? And if I getsome sagging, does getting more weight (planned anyway) will also fill up the skin so that it’s not so much of an issue ?
– when the medpor wings were shaved, doesn’t that necessarily suppose shaving integrated tissue/bone ? If so, does that mean I have now less bone structure than before ?
– Is there any way of moving a chin forward without making wider (and still blend in with the mandible) ? Is sliding genioplasty better at maintaining the original shape (since the bone already has the patient’s natural shape) ?
Thanks a lot for the time you spend helping out online.
A: One of the most overlooked features of chin augmentation is how it can change the front view. Most chin implants, particularly those of Medpor designs, will have an appreciable widening effect. When removing a chin implant, the issue is always one of the potential for soft tissue ptosis or sag. Just like a breast implant, once the tissues are expanded, they may not go back to their original shape. That is going tgo highly depend on the degree of expansion (size of the implant) an how long it has been in place. This can be partiually or completely overcome with mentalis muscle resuspension. Removing a Medpor implant does not mean losing any bone. The concept of bone ingrowth into Medpor is overstated and does not really occur to any appreciable degree, if at all. Removing the implant and doing a sliding genioplasty is a better alternative than just removing the implant alone. By so doing you will still end up with the profile improvement, keep a narrower chin (all sliding genioplasties actually keep or make the chin more narrow not wider) and will pick up any soft tissue and avoid/treat any soft tissue sagging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a mentalist strain and my chin is receding, I was told i needed a chin implant. Problem is that i’m not a fan of plastic surgery and I want to be natural. Is it still considered plastic surgery if I need it? Are there other options?
A: A small chin combined with a mentalis muscle strain is ideally treated with a sliding genioplasty. This brings the chin bone forward with the muscle and is a more effective and ‘natural’ (non-implant) solution to your problem. It is more effective because, rather than just stretching out the strained muscle which is already short, moving the chin bone forward actually lengthens the muscle by the bony movement. (thus eliminating the muscle strain) You may consider that approach a reconstructive solution to your chin concerns rather than a pure cosmetic one if that makes you feel more comfortable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if you could answer a quick question for me: Is there a way to perform a sliding genioplasty without having to cut the mentalis muscles? Is it possible to use an extraoral incision under the chin (if the patient didn’t care about small scars) to reduce damage to the underlying muscles of the lips? I am tired of hiding my face but I don’t think I’m brave enough to risk damaging the nerves or musculature of my lower face. How risky is this procedure?
A: Whether you go from inside the mouth or from below the chin, the mentalis muscle has to be cut. Even in a chin implant the muscle has to be cut. In skilled hands, a sliding genioplasty is a very safe and effective procedure with no long-term muscle or lip issues. The key is not whether the muscle is cut but if the surgeon knows how to put it back together.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested to know what can be done for my very short chin. I don’t know if I just need an implant or whether the jaw bone has to be moved. If you can answer a few questions for me I would appreciate it very much. 1) What is the biggest chin implant in terms of maximal horizontal projection? 2) How much can a sliding genioplasty move the chin forward? 3) Can sliding genioplasty be combined with an implant? 4) Can the entire lower jaw be moved without changing my bite? 5) How do you correct chin deficiencies larger than 10 mm? 6) How do you correct vertical deficiencies? 7) Does the implant feel natural and is there any risk of shifting after surgery?
A: The person with a very short chin poses challenges that often neither a standard chin implant or a sliding genioplasty can ideally solve. In answer to your questions:
1) The maximum horizontal projection for most chin implants is 12 mms.
2) How much a sliding genioplasty can advance the chin depends on the thickness of the mandibular symphyseal bone. That could translate into a 10 to 12mm chin point forward movement.
3) Yes. An implant can be overlaid in front of a sliding genioplasty to gain more horizontal projection or width.
4) No. The mandibular body and ramus can not be changed without carrying the attached teeth with it also, thus changing the occlusal relationship to the upper teeth. By definition, jaw advancement surgery changes the bite.
5) Options include a custom designed chin implant or a sliding genioplasty with an implant placed in front of it.
6) Vertical chin deficiences require a custom implant and are a component of every horizontal chin deficiency greater than 10mms. When the chin is that short it indicates there is an overall jaw shortness.
7) The implant will feel like bone and is screwed into place to prevent the postoperative risk of shifting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m 4 months out from having upper and lower jaw surgery. A 2.5mm upper advancement with a 4mm transverse expansion and 3mm posterior impaction to correct an anterior open bite, along with a 3.5mm lower advancement through a BSSO. In addition to this, I had a 7mm chin augmentation through sliding genioplasty. While everything else went perfectly well, unfortunately the genioplasty ended up asymmetrical.
I’ve attached both frontal and profile pictures for you here, as well as frontal and profile pictures from before the surgery. In addition, my latest panoramic x-ray is included as well. I’ve also included a picture of my sulcus as it was before surgery, and as it currently looks now, as well as a “relaxed lip” picture as I believe I show more lower incisors at rest than I used to. Forgive the photo quality…interestingly, I look much worse in photos than in 3-dimensions. I’ve never been terribly photogenic. In addition, I have a bit of residual swelling in my upper center face.
In any case, obviously, I’d like to have the asymmetry corrected (I think its very obvious). So, I have these questions:
1) How difficult is it to correct? My OMS seemed to be very reluctant to do a correction and implied it could be very difficult which is why I’m looking to you for correction based on several recommendations I’ve received about your work. Do you think I be better off with fillers or pre-jowl implants to mask the asymmetry rather than redoing the osteotomy? There are also those pesky “dents” on either side of my chin (pre-jowl)…
2) Is there a risk of more lower lip drop–greater than the first surgery? I did notice my lower lip dropped a little bit…perhaps 1-3mm though I can’t be completely sure as I never really looked at it before and don’t have any previous pictures of my lips in repose. It’s obviously not a devastating lip drop/incompetence issue as I’ve heard about. Do you see anything with the sulcus that looks abnormal in any way? Would an additional surgery in this area be more risky in this respect? If there is a problem…can it be corrected?
I’m planning on coming up there in the next 4-6 weeks for an in-person consult, but wanted to get an initial opinion from you as to what you believe needs to be done.
A: Thank for detailing your surgery and sending your pictures. Now that you are four months out from surgery, you can see largely see the effects of the surgery as all of the swelling has subsided and the tissues hav contracted back done to the bones. What I see is the chin asymmetry and the very typical notching at the back end of the osteotomy sites which can occur from a sliding genioplasty based on how it is cut. (angle) Your lower lip position is hard for me to judge since how you are now is all I know. But I will assyme that there is a slight lower lip sag/ptosis.
In terms of improvement, two out of three issues are straightforward. First, the jawline indents will need to be filled in which can be done with either a shaped mersilene mesh overlay implant or a wrap-around prejowl silicone implant. (1mm thick in the middle so it adds no further horizontal augmentation) Second, since an intraoral approach would be redone the mentallis muscle would just be repositioned and resuspended not only as a prevention of any further sag but may actually improve where your lower lip is now. Lastly, the bony chin asymmetry can be delt with two ways, eitehr reposition the genioplasty or shave down the large or more prominent side. Since you may be getting an overlay implant anyway I would think burring the bone is far simpler. The only reason to reposition the genioplasty is if there are other dimensions to it you want to change. I suspect what has happened is that with the typical central plate fixation used, one side got rotated a bit (no lateral stabilization) and the asymmetry resulted. The genioplasty can be recut and repositioned without a problem (never confuse can with want to) but you just should have a godo reason to do so and to make sure that something simpler may not work just as effectively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering how much of an advancement in millimeters via either an implant or genioplasty to achieve a more masculine chin and does my deep groove effect the outcome. Thanks.
A: How much chin advancement any patient can obtain depends on their anatomy. For a sliding genioplasty it is usually up to 12mms based on the front to back distance of the thickness of the chin bone. An implant can do more as it is based on how the implantg is fabricated, how much the soft tissue can stretch and the placement of the submental incision to place it. Increases in horizontal projections with chin implants can be done up to 15 to 18mms. In some cases, a coimbination of a sliding geniplasty with an implant overlay can be done with increases up to 20mms.
Any amount of chin advancement, no matter how it will done, does not change the labiomental sulcus and, in cases of significant advancement, will make it deeper. In a genioplasty the ‘step’ in the bone can be filled in to help preventing worsening the depth of the sulcus. In chin implants, the best simultaneous treatment would be fat injections placed directly beneath the sulcus.
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, many thanks for your email reply and I have attached some more pictures. Hope they are of the correct type – if you need better quality or closer views I can arrange that. As you can see I’ve taken photos of my profile many times and at varying body weights. The thinner I am the better my jawline looks, obviously, but I find it difficult to maintain the weight that allows this (roughly 50kg) – also I worry about when I get pregnant that I will look terrible with a big double chin.
My main concerns are that, from the front, my lower face looks chubby with jowls just to the right and left of my chin. I feel this makes me look really young but not in a good way!Like a chubby little girl! From a side(but not complete profile) view the jaw line gets hazy-looking about halfway along. In profile my chin just looks really weak which, to be honest, I wouldn’t mind so much but its the fact that this causes my neck structures to be poorly supported and therefore have a double chin. I also feel that my lower jaw is asymetrical and this can be seen from the front? Think that the left side of jaw is shorter making jowls worse on that side?
I have pushed my lower jaw out in some of the pics to get a view of what things might look like if I have a better jaw line/chin but obviously this gives me a horrible underbite and can’t walk around looking like that all day! But thought you might be interested to see the jawline I have in mind and I would hope for.
I included a pic of me at a lower weight to show you the effect of that as well….maybe I just need to knuckle down and lose the weight because currently I eat whatever I want and do NO EXERCISE at all…very bad I know!
Feel that my nose is quite fat looking at the lower portion from the front although I don’t have too much of an issue with the view in profile. Can something be done to make nose less bulbous at the end? This is definitely less of a concern for me the as it’s my chin that I really hate and think about it pretty much every day and am self conscious about it.
Many thanks.
A: Thank you for sending your pictures. What they show and you demonstrate so well is that the chin/jawline is somewhat short. Lengthening the chin by jawline distraction produces a good improvement. This manuever demonstrates to me that a sliding genioplasty would be a better treatment choice than a chin implant. Moving the chin bone forward brings with it the the underlying neck musculature and, as a result, produces a better jawline/neck appearance. One may also consider submental liposuction with the chin advancement to ensure getting the best result possible. As for the jowl asymmetry, the chin bone would be advanced symmetrically and hopefully that will make an improvement in that concern as well.
As for the nose, that would require a straightforward tip rhinoplasty to thin the cartilages and make the tip less bulbous.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, My face needs a vertical augmentation about 8mm and a horizontal one about 5mm or so. Yesterday I met a doctor in our area, he told me that with an Osteotomy surgery he can give it a nearly 2 to 3mm of vertical projection and about 3 to 4mm of horizontal projection, and above that level is impossible. He described that they cut a piece of my chin from its below, with a triangle section (kinda similar to a wedge I guess) and slide it forward and downward. I wanted to get your advice about how the surgery could be more efficient for me and how I can reach my desirable face.
A: You are referring to a sliding genioplasty procedure. The dimensional movements to which you have been told are far below what is possible. While I don’t know what your chin looks like, I would see no reason why you couldn’t have an 8mm vertical elongation and a 5 to 6mms horizontal advancement. Such movements are possible because of the use of specially designed chin plates that can be adjusted for a wide variety of chin movements to hold the bone in the desired position. I have no idea why you have been given those small chin movements as being what is possible. But to say that 8mm of length and 5 to 6mms of horizontal increase are impossible is not accurate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, I’m a female with a fairly prominent brow and small, receding forehead I’d like to improve. My face as a whole is convex rather than flat: Can the areas outside my eyes be “filled?” How would forehead augmentation affect deep wrinkles? Thank you!
A: Thank you for sending the edited picture. What I see is a mildly recessed forehead and a very recessed chin. The combination of the two is why your facial profile is convex. I have done some imaging for a forehead augmentation (not brow) and a chin osteotomy or sliding genioplasty. Your chin is too short for an implant and it also needs some vertical lengthening as well as bringing it horizontally forward. Also forehead augmentation usually will soften deep horizontal wrinkles as the skin is stretched out by the underlying material expansion.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, my goal is a harmonious and ideal ‘male model’ look profile via rhinoplasty and possibly horizontal and vertical chin augment if rhinoplasty is not enough. I want to have rhinoplasty done to correct my deviated septum, hanging columella, raise my tip slightly and smooth a slight nasal hump. I’m wondering if I can get away with rhinoplasty alone to enhance my profile? I feel my chin is a little weak (I have an overbite ~ class II). I did orthodontics/braces to correct my crooked teeth only, but not my bite. I don’t want jaw surgery because I’m OK with my bite function.
Concern: My deep labiomental fold that is between my lower lip and chin. Will a chin augmentation hurt, help or not effect this crease? I don’t want to make this crease worse, I either want it unchanged or improved.
Questions: Chin
Which procedure is recommended to produce an ideal result. Implant, genioplasty or doing nothing?
If implant, how big and what type should be used?
If genioplasty, what kind of cut would be done horizontal?
Will a chin augmentation hurt, help or not not effect labiomental crease??
A: In answer to your questions;
1) You absolutely can not get away with just a rhinoplasty alone to improve your profile. Your chin position is just too short. For your profile and overall facial aesthetics, chin correction is actually more important than the rhinoplasty.
2) Your chin correction should ideally be done by a sliding genioplasty because you have both a horizontal and a vertical chin deficiency.
3) The vertical component of the sliding genioplasty will allow the depth of the labiomental sulcus depth to remain unchanged as the chin comes forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to have breast implants, rhinoplasty and mentoplasty. (no implant) Do you offer mentoplasty? If so would I be able to do these 3 procedures at once or if not I would wait to do the implants. I can send some detailed pictures if needed.
A: Thank you for your inquiry. You certainly can do breast augmentation, rhinoplasty and chin augmentation all during the same surgery. When you refer to a non-implant mentoplasty, I assume you are referring to a sliding genioplasty in which the chin bone is moved forward. That accounts for about 25% of all chin procedures that I do so it is a chin augmentation technique in which I have great familiarity.
To help prepare accurate quoting, please send me some pictures of these areas so I can see exactly what needs to be done and the time it takes to do it. This is most relevant for the nose as there is great variability in rhinoplasty surgery depending upon how much of the nose structures need to be changed.
Once I have received the photos, I will do some computer imaging for the nose and chin and have my assistant send you a collective cost quote.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I really wanted to advance my chin and make my jawline straighter. I know I will need a sliding genioplasty and perhaps bone cement along the sides of my jawline. I was wondering if what I had in mind is possible and have done my own before and after to show you whicih I have attached. I like how the part below my lip and above my chin comes out almost like the jaw was moved forward, along with the the extension of my chin and straightness of the middle part of my jawline. Is all of this possible ? I don’t want to use any kind of implant, just my bone and bone cement. Can you make a custom 3D implant mold and place bone cement in that instead of using an implant ?
A: What you are demonstrating is the classic change that would occur from a sliding genioplasty. There is no need for bone cement or 3D model fabrications to get there. The chin bone (not the jaw bone) is cut and moved forward and plated into position. While silicone synthetic implants can be made from a 3-D model you can not use bone cement to create an implant as it is too brittle.
Dr. Barry Eppley
Indianapolis, Indiana