Your Questions
Your Questions
Q: Dr. Eppley, five years ago I had a sliding genioplasty to increase the projection of my chin. The titanium plates and screws are still in place. Although I am very happy with the new projection of my chin, I would like to have a decrease in the vertical length of my chin. Is it possible to simply cut out the bone below the titanium screws (below the red line on my x-ray pic) My surgeon told me that there are special muscles attached to this area and for this reason this wouldn´t be possible. This would lead to a droopy chin. He told me that vertical reduction of the chin could only be achieved by cutting out a horizontal slice of bone between the chin. What is your opinion on this?
A: To decrease the vertical height of the chin, if you are using an intraoral approach, it would be better to redo the horizontal osteotomy for the sake of keeping the soft tissues attached to the underside of the chin bone. The challenge in repeat sliding genioplasties is not the bone cut or removing the needed amount of bone but getting the old plate and screws out. Sometimes this can be next to impossible particularly if more than one screwheads sheers off. It is for this reason that removing a wedge of bone on the underside of the chin is appealing. Knowing how to reattach the muscles (mentalis muscle resuspension) is the key to successfully using that approach for vertical chin reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had two chin implants that had various problems so I opted for sliding genioplasty. For this surgery my surgeon drawn some sketches on my x-ray tracing which added 6 mm. I knew my prior implants didn't give vertical length and 6 mm looked fine and he explained about soft tissue draping that it would add some fullness too. I showed him examples of the chin I would like to have. And he said it’s possible. But now I am utterly frustrated as even after talking things through and showing him what I wanted I am stuck with how my chin looked like with an implant with very little added vertical length. Please let me know your thoughts. Should I ask for revision? When I told him my concerns, he said not more than 5-6 mm is possible with sliding genioplasty because that is what the metal plate allows.
A: My only comments are:
The step chin osteotomy plates go out to 10 to 12 mms, depending upon the manufacturer. I am not familiar with a 6mm advancement limitation by the fixation device. In some patients, there may be a bone thickness limitation for the amount of forward movement that can be achieved.
When measuring the chin bone for advancement by a sliding genioplasty, the soft tissue does not add any fullness. It moves in a 1:1 relationship with the bone. Therefore, for example, if you want the soft tissue chin point to move 10mms to get a desired look then move the bone 10mms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just wanted to have a jawline. As you see from my pictures there really is no jawine. All I can see is that big neck and I always wanted too be able to wear a hat but when I do put a hat on all you see is my turkey neck. Man I want to someday to comfortably put a hat on. There is nothing worse than two chins but it could be worseso I just accepted it. I just finished working out after work, anything to try and prevent a third chin. I really am gratefulyou took the time to review my case.
A: Thank for sending the good profile pictures. I can clearly see your concerns and they are based on the issues of having some bony chin deficiency (with a ball of soft tissue on the end of it), a high hyoid bone and a relatively short neck. These three factors give you the jawline-neck appearance that you have and do make it a challenging problem. Necks like yours are not easy to improve in males. There is not just one procedure that will correct all three contributing anatomic issues so a dual approach has to be used. I would advance the chin with a sliding genioplasty to lengthen the jawline, pull some of the neck muscles forward with it and increase the chin prominence. That would also stretch out the redundant soft tissues of the chin over the advanced bone. At the same time, I would then perform a submentoplasty procedure designed to remove neck fat and tighten up the neck muscles from below to make a better neck angle. This combination (sliding genioplasty/submentoplasty) would make improvements as demonstrated in the attached computer imaging. This will not completely get rid of the neck skin roll that you are making when you tilt your head down but that would require a formal necklift which, may not only be further than you want to go at this point, but I would await to see your level of satisfaction with these other more ‘simpler’ procedures first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had previously two chin implants which failed to give the length I desired. So I had an sliding genioplasty two months back with implant removal. As the swelling has gone down I look almost same as I did with implant. My surgeon said he advanced my chin 6 mm downwards and 5 mm horizontally. Is it the maximum advancement possible with sliding genioplasty? Your wise thoughts will be very much appreciated.
A: I have several thoughts about your chin surgery history and your question. Did you and your surgeon have a good understanding before surgery using computer imaging as to your desired chin goals? Changing the chin is one of the most predictable of all aesthetic structural facial procedures as the bone/implant change is 1:1 with the overlying soft tissues. It seems very pecular to me that you could have had three chin surgeries, none of them with large chin changes, and still end up inadequate. The bony genioplasty movement of 5mms horizontally is not very significant and, regardless of whatever size chin implant was in before, I am not surprised that you look no different now. You essentially swapped out the change provided by an implant for that of an osteotomy but no more. (other than some vertical increase) When one trades out an implant for an osteotomy it is because the osteotomy can make dimensional changes that an implant can not. While chin implants are not capable of providing more than a few millimeters of vertical height increase, they are capable of 9 to 10mms of horizontal lengthening. The amount that a bony chin can be advanced is based on the thickness of the bone but in most cases the amount of lengthening can be 10 to 12mms as the back edge of the downfractured chin segment touches the front edge of the intact upper chin bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 32 year-old male and I would like a well-defined jawline. I have attached some pictures for your thoughts.
A: Thank you for your inquiry. When it comes to improving the 'jawline' that could mean various things to different people. Fundamentally it comes down to whether one wants the front of their jawline (chin), the back of their jawline (jaw angles) or both improved. Those distinctions are obviously important as they involve different procedures.
In looking at your photos, an obvious horizontal chin deficiency exists. That could be significantly improved by either a chin implant or a sliding genioplasty. There are advantages and disadvantages to either approach and, based on what I see so far, I would lean towards a sliding genioplasty which would advance your chin up to 12mms but would also narrow it a bit in the frontal view which may be aesthetically advantageous for you. I have attached some prediction imaging of that potential result from the side view. It is not clear, based on just one photo, that augmentation of your jaw angles would help improve your jawline. I have done some imaging on this grainy frntal photo but it is questionably helpful. Better photos would ultimately be needed to clarify this issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a variety if procedures including brown bone reduction, rhinoplasty, chin augmentation and correction of my chest which I think is a pectus excavatum deformity. I have attached a variety of pictures so you can see all of the problems. I would like to know what you think.
A: I have taken a careful look at your pictures and can make the following comments.
1) Your chest deformity is very slight and not a true form of pectus excavatum. Regardless of what it may be called, I see no surgical procedure that would be worthwhile. Given the mild nature of the sternal groove/depression, the only option would be to build up the sternum with an injection technique to avoid any significant visible scarring. The problem is that it would be virtually impossible to get a smooth result. Without such a result, you would end up with an equally distracting aesthetic problem.
2) Forehead/brow bone reduction is not an option for you due to the mild nature of the bossing and the need to have a scalp scar to do it. That is always a challenging problem in a male. The trade-off of a scalp scar is not a worthy exchange.
3) Your chin shows both a significant horizontal and vertical deficiency. Its amount of deficiency makes your nose look bigger than it really is. It is the one feature on your face that would make the most dramatic change. Because of these three-dimensional chin deficiences, a chin implant is not a good option as it only brings it forward. Only a sliding genioplasty can bring the chin forward and down which are the changes that you ideally need.
4) The only beneficial changes that I see in your nose is the tip. It could be made thinner. But I would not change the height nor the smoothness of the dorsal line. I would also not change the tip position by making it any shorter or have anymore upward rotation. In essence, a tip rhinoplasty is all that you need.
I have attached some computer imaging based on the chin and nose changes.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am a 37 year-old man who had a chin implant done put five months ago using biocoral in a subperiosteal position placed through the mouth. This was not my first intent to correct my chin. Afew years ago a sliding genioplasty was done which failed (muscles put the fragment back in position) This time it went bad again, implant and bad postop tension made the muscle attachment drop and intraoral incision is not healing properly. (granulation tissue is going out of stitch defects) I really need a surgeon confident in re-anchoring mentalis muscle. I also need correction of my implant to check if it’s transforming into bone properly, there is some imbalance to correct and a prominent screw to remove.
A: Let me first make some general comments about genioplasty just based on what you have described. First, Sliding gebnioplasties should not fail to hold their position in today’s world no matter how strong the mentalis muscles are. Contemporary plate and screw fixation holds any genioplasty in place. Either the fixation was not done properly or wire fixation was used, an historic method of fixation last used in the 1980s. Secondly, an hydroxyapatite block implant (biocoral) will never transform into bone. Bone may grow up against it but it will always be like a synthetic implant. Third, it is now apparent that you have a non-healing wound likely caused by chronic implant exposure and low-grade infection. This is confirmed by the granulation tissue present and the exposed screw. It is now apparent that this implant is doomed and there is no way muscle is going to be pulled up over it and heal. Either it is too big or chronically infected, but either way keeping the indwelling implant is doubtful. I suspect you are going to have to look at implant removal, a new sliding genioplasty done and mentalis muscle resuspenion to end up with a healed and an improved aesthetic result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my face is very unbalanced as my chin is very short. This also makes my neck look fat even though I am at a good body weight. I have attached some pictures for you to tell me what you can do for my really short chin. It looks like the lower part of my face is just missing.
A: Here is a side view prediction based on the combination of a chin bony advancement (sliding genioplasty) combined with an implant. Your horizontal chin deficiency exceeds 15mms which puts you well beyond what any conventional chin implant can do. A chin osteotomy will advance you up to 12mms, which is better, but also not ideal. Therefore, in cases like yours I will put an implant in front of the advanced chin bone as well that will add another 5mms to the projection. The addition of the implant also has the advantage of its extended lateral wings which will fill out the sides, making the chin a little more square. That is an advantage for a male who benefits by a more square chin anyway. In addition, your thicker neck tissues would simultaneously benefit by liposuction under the advanced chin area to try and thin that out a little but.
The combination of a chin osteotomy and implant combined with neck liposuction can make some significant changes as the imaging suggests. This type of ‘extreme chin augmentation’ is necessary to get the best result in larger male chin deficiences like yours.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I’m going to ask you a question you probably heard 10000 times. What procedures do I need to perform in order to get “the male model look” and look handsome? I think(I may be wrong) I need: Skull Reshaping, Cheek Augmentation, Chin Advancement, cheek and chin;jaw/mandibular Implants, nose rhinoplasty; lip reduction; Neck Contouring; I’ve attached a few photos of me. My face looks fat. That’s because i have about 20 pounds of excess fat.
A: You are correct in assuming that I have been asked that question a lot….and have subsequently done a lot of male facial sculpting surgery. In getting a better balanced and more defined facial shape in a male, there is a list of procedures to consider most of whom you have mentioned. But each face is different and therefore has different needs to improve its proportions and get closer to a more sculpted look. There is also the issue of priority and the associated cost to do them so making the proper diagnosis as to the anatomic problems is extremely important in surgical procedure selection.
Your most glaring anatomic problem is your severe lower jaw/chin deficiency. A short lower jaw makes the entire lower face both horizontally and vertically short. This is what contributes to your impression that your fat is fat…it is not. It is just that the lower 1/3 of your face is overpowered by the upper 2/3s. This is further accentuated in profile by a moderate nasal hump which makes the facial convexity worse.
Your most important procedure is to get the lower 1/3 of your face in proportion. This is beyond what a chin implant alone can do. You really need a chin osteotomy (sliding genioplasty) combined with a small square chin implant placed in front of it. Removing your nasal dorsal hump would then complement your facial profile. (see attached side profile prediction) These are the two most important procedures. Secondary consideration could also be given to cheek implants. (see attached front view prediction)
While some other procedures may be complementary, this is the foundation for helping you get closer to more of a ‘male model look’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want more angularity to my face. I want high cheekbones, a stronger jaw, an enhanced chin, and possibly removing fat from around my mouth. Do you this will give me what I want? I have attached pictures so you can show me what this may look like after.
A:I have done some imaging on the photos you have sent. Your photos are not the best quality for imaging (poor resolution, fuzzy) but I think they will illustrate the point.
To improve your facial shape, I believe you have correctly identified the structures to consider changing. Your face is somewhat vertically short and lacks keys points of angular definition. From a chin standpoint, you need vertical lengthening as well as increased horizontal projection. Unless one uses a custom implant, the chin can only be lengthened by a sliding genioplasty, it can be brought forward at the same time. I am estimating that you need 7mms of vertical lengthening and up to 9mms of horizontal projection increase. You may also benefit from jaw angle augmentation but your pictures are not good enough to do useful imaging for that evaluation. You would also benefit my higher cheekbones using implants and some perioral liposuction to remove some fat around your mouth area. I Have attached some imaging of these potential results, keeping in mind the limited nature of the quality of the original photographs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had two procedures done 20 yrs ago. I don’t know the name of the procedure but I had a large amount of gums showing when I used to smile. They cut my upper jaw and raised it up, so I didn’t have the “gummy” smile. I then had my chin moved forward 11mm. I believe I have some underlying scar tissue from my upper jaw surgery underneath my cheeks. When I smile, my cheeks stand out and my face looks disproportionate. Can this be improved? Also my chin is still somewhat horizontally short. Can it be moved further forward again?
A: Your original surgery was a LeFort I or maxillary impaction to shorten the upper jaw and a sliding genioplasty to move the chin forward. The fullness that you have/feel in your cheeks is not really scar tissue per se. It is due to the release of the facial tissues made during the vestibular incision for your maxillary osteotomy. This causes some of the tissues and their muscular attachments to retract out to the sides into the cheeks, creating increased cheek fullness and what I call a ‘LeFort Look’ which is classic. This has long been recognized and is why at the completion of the maxillary bone surgery the vestibular incision is closed in a V-Y fashion to restore the midfacial tissues position. At this point in time after surgery, these tissues can not be respositioned. It may be possible to remove some of the buccal fat pad to reduce this fullness.
From a chin standpoint, osseous genioplasties or chin osteotomes can be repeated. The only complicating factor could be the fixation hardware used to secure the bone from the original surgery. Whether it was wires or plates and screws, these devices often get covered by bone healing and can be difficult to remove, hence blocking a good bone cut. Depending upon the indwelling hardware, it may be preferable to consider an implant rather than a repeat osteotomy. Whether chin implant or osteotomy should now be done can be determined by a simple x-ray, like a panorex, so the type of hardware in place can be seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a mentalis muscle resuspension about 10 years ago. This was due to complications from a sliding genioplasty that made my chin huge, and a subsequent reduction a few years later. The suspension worked well but my lower gumline has slowly receded to the point where a few front teeth may be in jeopardy.Would dental implants affect the suspension in any way? It feels as if recently either my one tooth is infected or the suspension site has problems. Is it possible to redo the procedure if necessary? Also, would it be possible at this point to move the chin forward a bit due to some slack skin from the original procedures? Thank you for your time.
A: There are different types of mentalis muscle suspension procedures and I obviously don’t know which one you had done. Whether the suspension is the cause of your anterior mandibular gingival retraction I don’t know. But that issue aside, I see no reason that the teeth in jeopardy could not be removed and replaced by dental implants. The placement and soft tissue coverage around the implants would not negatively affect your prior suspension. It is always possible to redo your suspension at any time in the future. Moving the chin bone further forward (redoing your sliding genioplasty) would only help your soft tissue suspension effects as a whole new tightening of it would be done during that procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering having jaw surgery. We have email conversed before and I am impressed with your perception and knowledge. I hope you will help me in my search for answers. I have attached photos for you to review if you so choose. I wore braces in the past and had no teeth extracted. My orthodontist says I have a Class I occlusion. As you can see, I show 1-2 mm of upper teeth at rest. When I smile, I show all of my upper teeth. When I laugh, I show 2-3 mm of gum. When my teeth come together, my lips don’t, so I have have to strain to close them. This seems to have resulted in my chin having a dimpled look almost as though there is a “fullness” of something. What bothers me is the protrusion of my mouth above and below the lip area, the crease under my lower lip, and the straining of and dippled look of my chin. I like the position of my chin and don’t want it pushed back if my jaws are moved back. I’m not sure if I would aesthetically look better if my jaw were moved back 2-3 mm. I don’t desire that my lips look a lot smaller. Do you have any thoughts???
A: My overall thought is you are not a candidate for major orthognathic surgery. You have a Class 1 occlusion and the aesthetic skeletal maxillary and mandibular problems that it is causing does not justify bimaxillary (maxillary and mandibular setback) surgery. While it can be done it is, so to speak, a long slide for a short gain…and not without some significant risks of morbidty. The magnitude of the problem and its potential benefits does not justify the effort for what is to be achieved. In short, the balance of benefits vs risk is not favorable.
I think there are some other alternatives, however, that are more appropriate for your facial problems. You have a horizontally short chin and mentalis muscle strain. That would be better treated by a sliding genioplasty to move the chin bone forward and give you lower lip conpetence. That would also improve the mentalis muscle strain and perhaps some of the dimpling. As for the upper lip, I question whether anything should be done for just a few millimeters of a gummy smile at maximal smile excursion. I might consider a simple levator superioris muscle release and vestibuloplasty only to blunt the upper lip excursion seen on maximal smile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my question is in regards to my face shape. I am twenty years old and I feel my face is too wide. I am in very good shape but I feel as if my face doesn’t have the chiseled look I want. The problem is I believe my cheekbones are too wide and my jaw is too wide also. So I am asking can I somehow do a cheekbone reduction with a jaw reduction and a genioplasty to lengthen my face as a whole. Being only twenty I am strongly considering doing these procedures. I feel I am a relatively good looking guy as I have received many compliments over the years but its a choice I want to make for myself not others. Basically I want to have a male model look. I want something like that to make my face narrower and longer.
A: On a realistic basis you should look at lengthening your face. It is not really possible to have jaw narrowing although it is possible to have some cheek narrowing. A chin osteotomy (sliding genioplasty) can be done to vertically lengthen the face. I would do some computer imaging first to see how that changes the appearance of your face. That will likely create a slightly more narrow face effect. You may find that the need for cheekbone reduction may not be necessary. But let the computer imaging help you through this decision process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a long chin that goes straight down as apposed to sticking out a little bit. I would like to have my chin shaved down so it’s shorter and somehow have it stick out instead of going straight down. Another reason this problem is so severe is because I have an extreme-overjet, but I’m going to a dentist to try to find a solution to that problem.
A: Based on your description of your aesthetic chin concerns and desires, what you actually need is a chin osteotomy (bony genioplasty) not a chin bony burring. A chin osteotomy removes 5 to 7mm of vertical bony height AND can move the chin forward whatever number of millimeters is desired. This procedure gives you both a vertical chin reduction and horizontal chin projection. This is the only chin procedure that can make those changes, which sounds exactly like what you are looking for. If you send me a front and side picture, I can do some computer imaging to show you what those chin changes would be like.
In regards to your occlusal overjet, that dental bite problem may be a contributing factor to your horizontal chin shortness but does not affect the chin being too long. In looking at the one picture you have sent, I do not see any evidence that whatever overjet you have would represent a severe mandibular deficiency. You should have an orthodontic work-up but I do not think it likely that there is major orthognathic surgery in your future.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a receding chin and wonder if you can help me get a reolution for this problem. I guess a sliding genioplasty will benefit me and it will also correct the vertical growth of the chin which a chin implant will not. And will this surgery make my already narrow chin look more pointed if the chin is brought forward by more than 5 mm.
A: Here is a computer prediction of a sliding genioplasty for you. That is the correct procedure given the magnitude of your chin deficiency problem. I would also add submental ljposuction to give a better neck profile as well. You are correct in assuming that a 10mm to 12mm advancement will likely make your chin look slightly narrow in the frontal view. That can be overcome by adding a small pre-jowl implant in front of the osteotomy which will make the sides wider and lessen the palpable notching on the edges of the osteotomy where it joins the body of the mandible posteriorly.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question regarding revising a sliding genioplasty. About a year ago, I had a sliding genioplasty that moved my chin forward by 8mm. The recovery has been uneventful, and all numbness and swelling is gone. One problem, however, is that my upper chin/below my lower lip feels pretty tight. It takes a bit of effort to close my mouth completely and sometimes bothers my speech. Is there any way to fix that?
A: What you have is tightness of the mentalis muscle and shortening of the anterior mandibular vestibule. Because a sliding genioplasty is done through an intraoral approach and must take down the superior mentalis muscle attachments, the combination of stretching them (from the advancement) and scarring will cause the muscles to be short or adhered. This can likely be improved through a mentalis muscle release and resuspension with a V-Y mucosal inner lip advancement. I have seen this problem numerous times and successful improved it through this soft tissue repositioning approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have chin ptosis after the removal of a large chin implant. So what needs to be primarily done should be a mentalis resuspension. I am considering sliding genioplasty despite the risks of bone osteotomy, longer surgery time, and longer recovery time, only if it helps the result of the mentalis resuspension procedure. If genioplasty would have any negative effect or no effect on the mentalis resuspension procedure (i.e. more bleeding, swelling, more complications than the resuspension procedure alone), I would not want to have it done.
My question is, first of all, regarding [mentalis resuspension alone] vs. [mentalis resuspension + sliding genioplasty], would there be any difference in the result concerning the ptotic chin and lower lip disturbance? If there should be no actual difference, then I probably wouldn’t want the sliding genioplasty done due to longer recovery time and more risks. But, if the genioplasty should give any positive effect, I should consider it be done along with the mentalis resuspension procedure.
Secondly, my implant insertion and removal were both done by intraoral approach. Should the mentalis resuspension procedure be performed by intraoral approach again?
Lastly, you have mentioned the disruption of the attachments of labiomental sulcus as the cause of lower lip eversion disturbance. By the “attachments of labiomental sulcus”, do you mean the mentalis muscle attachment to the bone? Or is there any other muscle involved in this area? Does labiomental sulcus muscle repair simply mean resuspension of the mentalis muscle? Are there any other muscles that should be repaired to fix the attachments of labiomental sulcus?
A: The mentalis muscle suspension is infinitely improved by the concomitant sliding genioplasty as this procedure addresses one anatomic element that intraoral suspension does not…excess skin and subcutaneous tissues. Bone-occupying volume expansion with muscle tightening addresses all the issues of the ptotic chin problem.
The intraoral approach has disrupted the superior attachements of the muscle and, if only the mentalis muscle resuspension was going to be done, then you would do an intraoral approach for repair.
Labiomental sulcus disruption means the complete loss of superior mentalis muscle attachments. That is addressed in the intraoral mentalis muscle suspension procedure through the use of bone anchors.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin implant inserted 8 months ago, which turned out to be too big. I was very unsatisfied with the result and it was removed 2 months after the initial surgery, which is 6 months ago from now. The problem is that chin ptosis has developed. I am suspecting that adequate mentalis reattachment was not performed after the implant removal. Moreover, the central part of my lower lip would not move downwards, even when I smile widely, always covering my lower incisors totally. This seems different from typical lower lip incompetence caused by mentalis muscle ptosis, since I believe that ptosis of mentalis muscle causes lower lip to drop downward with inability to close mouth properly. This lower lip issue is not a newly developed problem, since it was present immediately after the initial implant insertion surgery and never went back to normal. Also, my lower lip seems to have become shorter in vertical length. My labiomental sulcus area looks like the soft tissue is fixed to the bone making it look unnatural when i speak or smile. I am thinking a mentalis resuspension would help my problems but my question is why would my lower lip not move downwards? This sometimes interfere with my pronunciation when I speak which bothers me a lot. One more question is would sliding genioplasty combined with mentalis resuspension give a better result than mentalis resuspension alone? I want to know the best solution to correct my problems. I am looking forward to your answer. Thank you.
A: You are correct in that the lower lip may sag with chin ptosis in some cases, but not always. Many chin ptosis patients have a normal lower lip position and function. Rarely you will have a patient like you who has the opposite lower lip problem in which the lip will not evert. This can occur if the implant was inserted from below (submental incision) and the implant pocket was made up close to the mandibular vestibule. This disrupts the attachments of the labiomental sulcus and blocks lower lip eversion. Even when the implant is subsequently removed, the muscle fibers remain disrupted.
Since there was a reason you had the chin implant in the first place, it would make the most sense to consider a sliding genioplasty. In that way all three problems can be simultaneously treated. (chin deficiency, chin ptosis, labiomental sulcus muscle repair)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a short face length with a small/narrow lower jaw. From the profile view my face looks even shorter because of my short forehead and short jaw. Could jaw implants fill out my lower jaw and make my lower/overall face look ‘bigger’? I’ve already had a chin implant, but it didn’t do much for vertical length. My plastic surgeon says a sliding genioplasty wouldn’t look good. Should I get a second opinion? Is it safe to get a sliding genioplasty and jaw implants at the same time? Thank you for your time.
A: The right style of jaw angle implants will vertically lengthen the posterior face. But the wrong style of jaw angle implant will only make it wider (fatter) and not longer.
Chin implants will not provide any vertical length, just horizontal projection. No stock chin implants are made for vertical chin elongation.
The statement that a sliding genioplasty won’t look good is a nonsensical opinion. A sliding genioplasty is the only option to provide vertical chin lengthening or lengthening of the anterior face. Just because a surgeon can’t do an osteotomy doesn’t mean it won’t look good or be a good choice for a particular patient.
It is common in my experience to do jaw angle implants with a chin osteotomy and/or an implant. They are often needed together to create an overall change in jaw shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in two facial procedures and I believe you are the right doctor to do them. I already have a chin implant in place but it is not ideal. I would like to have a sliding genioplasty to correct my underbite and have a slightly more balanced chin. Also I want buccal fat removal. I have a heavy lower face with full cheeks that I would like to look slightly more sculpted.
A: Based on the procedures you desire and your objectives, I would make the following comments and clarifications.
A sliding genioplasty is an alternative, and is sometimes better than a chin implant for more severe cases of chin deficiency. It will not, however, correct any occlusal problems as it is a chin procedure and not a total jaw advancement. The correction of one’s underbite requires a sagittal split ramus osteotomy jaw procedure (done in the back part of the lower jaw) which moves the tooth-bearing portion of the jaw bone. This requires pre- and post-surgical orthodontics. It fixes the bite as well as produces an amount of chin augmentation in millimeters that matches how far the lower teeth have moved to fit better to the upper teeth. Do not confuse a sliding genioplasty and a sagittal split mandibular osteotomy.
A buccal lipectomy removes fat and its associated fullness right under the cheek bone (submalar region) It does not create any slimming effect below this area. Most patients envision the entire cheek area done to and past the corner of the mouth when they refer to making their face less full. For this reason, many buccal lipectomies (done from a small incision inside the mouth) are combined with small cannula liposuction of the perioral mounds. (mound or fullness to the sides if the mouth or lower cheek region) This combination creates a better overall slimming effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin advancement by osteotomy last year but I am not happy with the result. My chin is still too short. I would like you to perform another chin osteotomy for further advancement. I still prefer the chin osteotomy because of its permanent result. I have attached some pictures for you to review. How much further do you think you can bring out my chin?
A: Thank you for sending your pictures. I can see by your side view photo that you still do not have optimal horizontal projection as you know. The key question in determining how much more horizontal advancement can be done with an osteotomy needs to be determined through a lateral cephalometric x-ray. The sliding genioplasty is based on the principle that as the lower chin bone segment moves forward, its back end or cortical segment maintains contact with the front edge or cortex of the attached upper chin segment. Some bone contact must remain between the two bone segments for it to survive and not resorb. It may be entirely possible that your chin was moved as far forward as the bone would permit. (unlikely) The real question in my mind is how much further can the chin bone be moved. That is where the value of the x-ray is so important. If it can only be moved 2 or 3mms further forward, an osteotomy approach may not be worth it. (I suspect it can be moved at least 5mms but I need to be sure) The x-ray will also show what type of bone fixation was used so there are no surprises during surgery. One would not want to run across some method of fixation that is very hard or impossible to fully remove and allow the bone to be mobilized. (e.g., lag screw fixation)
The x-ray ultimately needed is a simple lateral cephalometric or facial film view. That can be gotten at any orthodontist and most oral surgery offices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr Eppley, I am a boxer and wanted to get a sliding genioplasty. I am recessed by about 10mm’s and was wondering if I would be able to box after this chin surgery. If so, how long after surgery can I do so? Thanks for your time.
A: For your chin deficiency, a sliding genioplasty is probably a more wise decision than an implant given your boxing avocation/occupation. A chin implant may have also worked as long as it would be secured with 3 to 5 screws. It would have a quicker recovery and return to boxing (1 month if contact to face may occur, training part doesn’t matter) but there is always the potential for some implant related problem long-term if struck on the chin. (which I assume is common on boxing) For a chin osteotomy, the return to contact boxing should be 3 months at least although training could occur at any time one felt comfortable. You could argue that the bone is not really healed in a big advancement (10mms) for up to 6 months so this is a more conservative estimate. With the osteotomy in your case, I would secure it with more than the traditional chin plate (step plate) and 4 screws. I would probably add a small plate on each side of the sliding genioplasty for the extra security of the bone position.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am considering having augmentation for my short chin. I am confused as to whether to use an implant or move the bone. Doctors seem to recommend both ways and it is not clear as to which way may be best for me. Can you help me decide?
A: Your two main choices for chin augmentation are either an implant or a sliding osteotomy. Both will work and each has its own disadvantages and advantages. An implant is simpler, has a quicker recovery and can make the chin wider as it comes forward. (if you want to change your v-shaped chin in frontal view to a more round or even a more square shape) There are even square chin implants to help create that look. The only disadvantage is that it is an implant…although I don’t really see any lifelong problem with having an implant in the chin. That is a very safe place for a facial implant and it is not likely to ever cause any problems requiring its removal. The osteotomy involves moving the chin bone instead of an implant. It is a ‘bigger’ operation, requires a plate and screws and thus there is more expense. It’s main advantage over an implant is that it is better at increasing the vertical length of the chin should that be needed. An implant can not do that very well at all. Also in big horizontal advancements (8 to 10mms or more) in a young person, moving your own chin bone forward is probably better than having a big implant on the end of the chin. An implant can deepen the labiomental sulcus whereas an osteotomy can keep it from getting deeper than where it started. This means that it may look more natural in the long run for big chin advancements.
In the end, you have to look at the anatomy of your chin deficiency and determine whether an implant or osteotomy can correct it the best and the most natural. Other important consideration are your age and the economics of the surgery.
Dr. Barry Eppley
Indianapolis, Indiana