What Type of Revisional Surgery Do I Need For My Nose, Chin and Jaw Angles?

Q: Dr. Eppley, I had plastic surgery done nearly 4 years ago that has left me what I consider deformed. I don’t resemble myself and there were so many mistakes the doctor made to my face. I am deeply saddened and depressed over this not only because of the cost but that I’m left disfigured and violated. I had my nose done where the doctor inserted a silicone implant promising that he would be able to correct my slight deviation with it. That was not achieved and my nose appears even more deviated, my nose looks short, and my nostrils more visible. I have thin skin so I feel you can almost make out the implant when looking at me. I would very much like to correct the mentioned issues. Also he performed an extraoral jaw reduction on me that left me further disfigured. He overcorrected and now my face has the appearance of a horse. I would like to restore the lost volume and give my face back it’s natural contour. Not to mention the incisional scar is very unsightly. It’s almost two inches long and is hypertrophic and red. I would like to revise the scar to make it less noticeable. I also had a silicone chin implant placed but it does not fit my face. It’s too big and wide and I would just like it removed and possibly have fat grafting to that area instead. I would possibly like other areas to be fat grafted as well such as my nasolabial fold and the hollows of my eyes.

A: From a nose standpoint, if you had an initial nasal deviation overlaying silicone implant on a nose that is deviated will actually make the nasal deviation look worse not better. So your outcome is not a surprise since you have to lay the implant on the existing nasal base. With thin skin and implant encapsulation, implant visibility often appears years later. From a short nose and nostril visibility standpoint, I am not sure how an implant would have caused that per se with the exception of a high bridge and dorsal line may make the amount of tip projection/rotation perceptibly look shorter and more rotated. From a secondary rhinoplasty correction standpoint, it appears that the implant would need to be removed and cartilage grafting done to augment and lengthen the nose with tip derogation as well as correction of the underlying nasal deviation which almost certainly has a septal deviation as a core root of the problem. The question is where the cartilage needs to be harvested from and that would depend on how much is needed. The debate is always whether it would be a combined septal/ear donor site or whether more is needed which requires rib cartilage. I would need to see some side view pictures to have a better idea in that regard.

From your prior jaw reduction procedure, I am assuming that the incisions and now red scars are at the back of the jaw behind the angles. (a side view picture would show that better) When you say you have lost volume and has changed you facial appearance (I don’t know if I would go so far as calling it horse-like), that likely implies that it looks too long because of the lost jaw angle volume and a steeper mandibular plane angle. (high in back and steeply slopes downward towards the chin) Restoring lost volume from prior jaw reduction in my experience is done by adding a jawline implant closer to the lost angle area to add some vertical length and a little bit of width.

Revisions of the jaw angle reduction scars can certainly be done and would likely result in a better outcome since they would not have the original traction. (pulling and stretching the skin to cut the bone) The interesting question about your scars is whether that access should be used for the placement of the implants since you have them already. That would make your recovery much easier than from gong inside the mouth. Whether the implants can be used forms standard stock sizes or should be custom made from a 3D CT scan is another issue to debate.

One of the may problems with chin implants done in women is that they are are often too wide as extended anatomic styles are often used. The question here is whether it should be replaced with a smaller central button style chin implant (which is far more appropriate for female faces) or replace with a fat graft with its unknown survival rate.

Lastly, fat grafting can be done for the nasolabial folds and eye hollows with the only real issue bend their survival is the risk of some unevenness or lumpiness in the eye hollow area due to the thin skin. This can usually be minimized by using a micronized fat grafting technique where the fat particles are made very small before injecting.

I hope these comments are helpful and if you can send some side view pictures that would be useful for further analysis.

Dr. Barry Eppley

Indianapolis, Indiana