EXPLORE
Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘chin implant’ Category

Case Study – Jawline Augmentation using a Three Implant Technique

Wednesday, October 25th, 2017

 

Background: The shape of the lower face is primarily influenced by the size and dimensions of the mandible or lower jaw. Being the only moveable bone on the face it has a unique shape due to the biomechanical stresses placed on it as well as having to contain up to sixteen teeth that pass loading forces onto the upper jaw. It has three prominences that make up its identifiable tripartite structure, the anterior chin and the posterior jaw angles. While the chin is the mandible’s most recognized aesthetic feature, the jaw angles are really like the paired set of chins on the back part of the jaw.

While chin augmentation has been around for over five decades, jaw angle augmentation is much more recent. Unlike the chin, augmentation of the jaw angles can only be done by implants and doing so is far more complicated than that of the chin. Besides the anatomic fact there are two jaw angles, their location underneath the strong masseter muscles creates considerations of incision location, implant shape and size and its location on the bone and how it may affect muscular position and shape.

While the ideal method for total jawline augmentation is that of a custom made wrap around jawline implant, many patient’s may not need that technology or prefer not to undergo its use. Standard chin and jaw angle implants can work well for many patients and their wide variety of sizes and shapes create a lot of aesthetic jawline augmentation options. But how to mix and match these implant sizes and the challenges of placing three separate implants in their proper bony positions makes getting symmetric and aesthetically satisfying results challenging.

Case Study: This young male wanted a total jawline augmentation with a result that was of a modest enhancing effect. He didn’t want it too strong or to look overdone. His natural jaw was not weak or overtly deficient but had softer highlights of the chin and jaw angles.

Under general anesthesia, a small square chin implant was placed through a submental incision. Through posterior vestibular intraoral incisions, medium square widening jaw angle implants were placed and secured by titanium micro screws.

His after surgery results showed a more defined jawline that had better chin and jaw angle angularity. The implants had acceptable symmetry and were not oversized.

While this patient had a good result using standard chin and jaw angle implants, the risks of revisional surgery with three independent bone areas of augmentation is not low. Between the size and shape of the implants and their proper and symmetric placement on the bone, the average risk of an aesthetic revision for the dozens of influencing and interconnected possible variables is 50% or higher.

Highlights:

  1. Complete jawline augmentation consists of highlighting the three corners of the jaw, the chin and bilateral jaw angles.
  2. A wide variety of standard chin and jaw angle implants exist to satisfy many patient’s aesthetic jawline needs.
  3. With three independent implants along the jawline it is important that patient’s appreciate the relatively high rate of aesthetic revisions that can occur.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sliding Genioplasty Combined with Chin Implant

Friday, October 6th, 2017

 

Background: Routine chin deficiencies are well managed by with an implant or a sliding genioplasty. The concept of a routine chin augmentation, in my experience, generally falls into a horizontal chin position movement of 10mms for less. Once the aesthetic need becomes greater than a centimeter there is undoubtably an overall lower jaw skeletal deficiency that should ideally managed by a combined orthodontic-orthognathic surgery approach.

But some lower jaw deficient patients will never undergo movement of the entire lower jaw and teeth positions for a variety of reasons. They may appear just for chin augmentation only as a camouflage approach to their lower facial deficiency.

While a large chin implant can be used, most standard chin implants do not provide more than 10mms of horizontal advancement. While larger custom chin implants can be made, such a load of synthetic material on the chin may exceed the soft tissue stretch to safely accommodate it. The projection off such a large chin implant may also appear unnatural with a much thinner jawline behind it.

A sliding genioplasty can usually exceed 10mms if the bone thickness will allow it. I have seen it often go to 14 to 16mms. But in such large tiny chin movements there will be pronounced stepoffs on their sides and the labiomental fold will definitely get much deeper as the bone underneath it has become deeper as the lower chin point comes forward.

Case Study: This young male has a large chin deficiency with a skeletally short lower jaw. From an ideal chin projection standpoint for a male (vertical line dropped down from the lips) he was 22mms horizontally short. Orthognathic surgery was not an option that he wanted to pursue.

Under general anesthesia, an intraoral sliding genioplasty was performed with 14mms of horizontal advancement based in the limits of maintaining bone contact. (lingual cortex of lower chin segment with buccal cortex of upper chin segment) To add a little extra to the what moving the bone achieved a 5mm extended anatomic chin implant was placed in front of the front edge of the chin bone. The wings of the implant went back along the sides of the advanced chin segment across the step off area. Due to the large step-off created an hydroxyapatite block was placed to prevent a severe deepening of the labiomental fold. (the fold is always going to get deeper in larger chin augmentations, you just want to try and lessen that effect)

The need for a combined sliding genioplasty and implant for aesthetic chin augmentation is rare and is avoided by the traditional use of orthographic surgery. The value of such a chin implant is three-fold; 1) its a small amount of additional horizontal augmentation, 2) its wings can cover up the indentation along the sides of larger sliding genioplasty movements (the concave jawline deformity) and 3) it keeps the chin from looking too thin in the frontal view.

It is not a mortal surgical sin to combine two chin augmentation methods that are often viewed as competitive procedures. Each has their own distinct aesthetic effects and in rare cases may be used synergistically to create a better aesthetic outcome than either one can achieve alone.

Highlights:

  1. Large chin deficiencies are often beyond what a sliding genioplasty or a chin implant can effectively treat alone.
  2. Combining a sliding genioplaty with a chin implant can maximize the amount of horizontal advancement and cover bony step offs on the sides. 
  3. Large sliding genioplasty movements will require fill of the step-off to avoid a severe deepening of the labiomental fold.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Goretex Chin Implant Removal

Monday, September 4th, 2017

 

Chin augmentation has been one of the most popular facial reshaping procedures for decades. Since its inception in the 1950s, a wide variety of materials have been used for chin implants. Despite this diversity of implanted materials, the silicone chin implant remains the primary implant used due to large number of different styles and sizes, ease of insertion and ease of removal if needed.

One of the chin implant materials used in the late 1990s and early 2000s was that of Goretex, also known as expanded polytetrafluroethylene. Its value as a facial implant material is that it does allow some tissue adherence to develop once implanted. Its microporous surface combined with a fluorine-containing composition allows for tissues to stick to it. This tissue adherence is not as great as Medpor, for example, but is better than that of silicone. Despite these material benefits, it never enjoyed widespread popularity before the product line and the company that made it eventually disappeared into the annals of plastic surgery history.

Every now and then a patient will appear who requests the removal of a Gore-tex chin implant that was placed a long time ago. The request for removal is not usually because it is having any specific medical problems but due a desire to return to their original chin shape before they had the implant placed. This is actually not rare as what one may have wanted at one point in life may change years to decades later.

Gortex chin implant removal can be done uneventfully and it can be removed intact with gentle dissection around all implant surfaces first before attempting extraction. Such chin implants are easily recognizable by both its white color as well as the layered composition which represents the layers of Goretex material which have been compressed together and then machined into the implant’s shape.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Chin Implant Asymmetry Correction

Sunday, May 21st, 2017

 

Background: Chin implants are well known to induce a variety of tissue reactions around the implant site. A surrounding encapsulation of scar tissue is always seen as occurs in every synthetic implant placed in the body. ‘Bone resorption‘ is often cited as an adverse reaction to chin implants but this is a misinterpretation of the actual biologic response that has occurred. It is more accurately described as a limited and passive bone remodeling as a response to the recoil of the expanded tight chin pad tissues now overlying the implant. It is, in effect, a pressure relief.

Some limited bone overgrowth around the edges of the implant is also not uncommonly seen. This occurs because the implant is placed in a subperiosteal location from which a limited osteogenic response is seen from the disturbed periosteal layer. It is actually rather remarkable that bone would grow up over portions of the implant given that it is a synthetic material. But this speaks to the osteogenic potential of the periosteum. But when such a bony overgrowth is seen it is limited to just the edge of the implant, usually the lower edge.

Case Study: This 35 year female had an anatomic chin implant placed eight years previously. While she liked the general chin augmentation effect, there were several aesthetic issues that developed from it that she didn’t like. The implant had some asymmetry to it with the left wing higher than that of the right. There were also multiple indentations that had developed over the soft tissue chin pad that were present at rest and became magnified when she smiled.

Under general anesthesia and through her existing submental incision, dissection was carried down to the chin bone. Initially the chin implant could not be found as only bone could be seen.Tapping on the chin bone had a hollow sound to it. It was suspected that bone had overgrown the bottom edge of the implant and its outer layer was chipped off with an osteotome over a small area to reveal the implant underneath. Continuing to remove the bone overgrowth eventually revealed that the entire implant was completely encased in bone including over the small lateral wings of the implant. The total bony ovegrowth was removed and the implant extracted. All edges of the bony overgrowth down to normal bone was removed. The implant was re-inserted and position in a midline neutral position and secured with double microscrew fixation to prevent implant rotation and recurrent asymmetry.

Complete bony overgrowth of an extended chin implant is a tissue reaction that I have not seen occur. Partial bony overgrowth occasionally occurs  but never complete bony encasement. Such a bony reaction to the implant could be the source of the overlying soft tissue chin pad indentations due to tethering into the tissues. It remains to be seen if removal of the bone improves these indentations.

It is important in treating chin implant asymmetry that any impedance to the wings of the implant be released/removed to allow the total implant to have achieve a completely horizontal orientation. Usually this involves a release of the surrounding scar capsule. In this case it involved all raised bony edges.

Highlights:

  1. Chin implants often induce local tissue reactions including bone overgrowth.
  2. Complete bony encasement of a silicone chin implant is not an implant reaction that I have seen previously.
  3. Chin implant asymmetry correction requires that all surrounding bony overgrowth must be removed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Mersilene Mesh Chin Implant Replacement

Saturday, May 20th, 2017

 

Background: Chin augmentation is one of the oldest facial reshaping procedures. It has been performed for over fifty years and just about every conceivable material has been used to perform it. But historically and currently silicone implants have been preferred due to the wide variety of styles and sizes that are commercially available as well as their ease of insertion and removal.

But silicone implants are not perfect as they do not permit tissue ingrowth into them or attach firmly to the surrounding tissues. (depending upon how you view it this can be an advantage as well as a disadvantage) This lack of tissue adherence has allowed the use of a few select biomaterials for chin augmentation that have tissue adherence by virtue of having surface porosity or actual intermaterial porosity

One of these porous materials is mersilene mesh. Mersilene mesh is a synthetic non-resorbable polyester fiber that looks and feels like a fine mesh screen.  This mesh structure allows for fibrovascular ingrowth. It comes in thin sheets that are easily cut and has been widely used in hernia repair. But it has been applied for many other medical applications from ptosis eyelid repair to vaginal and urethral slings. It can be folded into a multilayer shape and sutured together to create a ‘chin implant’.

Case Study: This 30 year female had a history of two prior chin implant surgeries. She originally had a small anatomic chin implant which she felt produced inadequate projection and not the desired v-shape to the chin. It was subsequently replaced by a mersilene mesh implant to improve its projection and shape. This second chin implant ended up looking more like a block on the end of the chin and was further removed form the desired chin look.

Under general anesthesia and through the existing submental incision, the mersilene mesh material was tediously removed due to ingrowth of the surrounding soft tissues. It not only was stuck to the overlying tissues but had left an imprint on the underlying bone. (passive underlying resorption) An anatomic silicone chin implant was used as a replacement and its sides was tapered into more of a v-shape with s scalpel technique. The new implant was placed more on the bottom edge of the chin bone to add some vertical projection as well.

Mersilene mesh chin implants can be successfully removed with careful technique. Patients should expect more postoperative swelling than the original placement surgery due to the increased tissue dissection needed.

Highlights:

  1. Despite tissue ingrowth mersilene mesh chin implants can be successfully removed.
  2. Mersilene mesh material leaves impressions in the bone like every other type of chin implant.
  3. The shape options in mesh style implants are limited and can be the reason for chin implant replacement.

Dr. Barry Eppley

Indianapolis, Indiana

Square Chin Implant in Men

Monday, May 8th, 2017

 

As the chin is usually the most protrusive part of  the lower face, its shape is clearly evident. While the shape of the human chin is highly variable there are some general trends based on gender. The male chin is known to usually be bigger than that of females in both projection but almost always in width. The male chin width can be round or more square-like based on genetics and growth.

The square chin has been for some time and remains currently a desired male facial trait. There has always been a lot of conjecture that it is an appealing facial feature to women due to the evolutionary need for procreation and furtherance of the species. It implies strength and virility and the appearance of a ‘high testosterone’ level. At the least its angular appearance adds facial highlights and makes the face more interesting.

In chin augmentation the only way to make a chin wider and more square is with an implant to do so. Of all the styles of jaw implants that are available, a square chin implant style does exist. It differs from most chin implants in that rather than having a round comfigurarion, it has more of a U shape. This broad U-shape makes for a more square chin appearance by adding thickness between the transition between the chin and the side of the jawline.

The square chin implant is usually placed through a submental incision since it is used exclusively in men who can easily tolerate this incisional approach. The additional width of the implant requires that a good pocket is created along the sides of the jawline to accommodate the long winds of this chin implant style.

There are two square chin implant styles, style 1 and style 2. Style 1 is more narrow (45mms) than Style 2. (55mms) The key to selection of which chin implant style is the width of the mouth. As  a general rule the width of a square chin implant should be no greater than a vertical line dropped down from the corners of the mouth on each side. When the chin width exceeds the width off the mouth it can look unnatural.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Chin-Jawline Implant

Saturday, April 29th, 2017

 

Chin augmentation has been done for a long time and many different implant materials and shapes have been used. The most common chin implant used today is that of an extended or anatomic design. Rather than just sitting on the front edge of the chin this contemporary chin implant is anatomic as its side wings blend along and into the lateral jawline to the sides of the chin.

But as useful as the anatomic chin implant is, it does not augment much of the jawline behind it. It remains a front of the lower jaw augmentation method only.

An extension of the anatomic chin implant is what I call a chin-jawline implant. It is a chin implant that has winged extensions that go back all the way along the jawline…stopping just short of the jaw angle area. This creates greater definition of the jawline although not much width due to the thinness of the extensions.

It is inserted just like any chin implant through either a submental or intraoral incision. A submental incision, however, is preferred as it allows a direct line dissection with long instruments back along the jawline. Despite their aesthetic advantages in properly selected patients, the long extensions offer an opportunity for displacement and asymmetry. Small intraoral incisions can be made to check the most posterior portion of the wings go ensure their smooth positioning along the jawline if desired.

The chin-jawline implant offers enhanced bone definition of the lower lateral border of the jawline. It is useful with jaw angle implants to create a total jawline augmentation effect, to improve jawline definition of a lower facelift and to extend the benefits of chin augmentation. It is available in male and female versions that differ in the shape of the chin with the male being more square and the female being rounded,.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Sliding Genioplasty with Chin Implant

Thursday, March 16th, 2017

 

Chin augmentation can be done through either placing an implant on top of the bone or moving the actual bone forward. Both are valid chin enhancement techniques and each has their own unique advantages and disadvantages. While there are strong surgeon advocates for both techniques, it is important to remember that not every patient is appropriate for either one and what matters for good results is matching the solution to the problem and not surgeon preference or familiarity with either surgical method.

There are rare instances where a sliding genioplasty and a chin implant can be combined. There are two indications for this composite chin augmentation approach. The first one is when the amount of horizontal chin augmentation desired is more than what a sliding genioplasty alone can produce. This would occur when the thickness of the chin bone is less than what the amount of horizontal bone movement that is needed to create the desired effect can be done. The additional horizontal projection is achieved by placing the  needed implant size in front of the moved chin bone.

The second indication for the composite chin augmentation approach is when one desires a different chin shape than that of the natural bone of the sliding genioplasty. This almost is always when one wants a more square chin shape and the natural chin bone is more round. A more square shaped chin implant, even if it is small, is placed in front of the sliding genioplasty. It is vey difficult, if not impossible in many cases, to make the chin bone more square in external appearance.

Sliding Genioplasty with Chin Implant Dr Barry Eppley IndianapolisWhen placing an implant in front of the sliding genioplasty, it is important to realize up front, that there will be some eventual implant settling into the bone. This is not bone erosion but simply the body seeking to relieve the pressure from the pushback of the stretched chin soft tissue pad. It is a natural and self-limiting biologic process.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Double Chin Correction

Tuesday, February 21st, 2017

 

Background: The shape of the chin has a major effect on facial appearance. Since the chin is a projecting facial structure, it highly influences the shape of the face and how defined the neck can look. The shorter the chin becomes the more convex the facial profile becomes and the neck looks increasingly ‘lost’.

A common aesthetic facial concern is that of the Double Chin. This is really an urban term that is a misnomer. It is not really a double chin per se, it is really a chin deficiency or lack of enough chin projection. When combined with even a small amount of excess neck fat, which occurs right under the chin (submental fat), the profile will show two humps or mounds. They may look like two projecting chins but the lower ‘chin’ ir excessive neck fat.

The treatment of the double chin is a classic diametric surgery. Each ‘chin’ change must be in opposite directions to create the best facial profile change. The upper ‘chin’ must be moved forward and requires some type of bony procedure. (implant vs sliding genioplasty) The lower ‘chin’ requires soft tissue reduction using liposuction fat removal. Together the entire lower face is improved as it becomes more ‘pulled out’ and defined.

Case Study: This 45 year-old female was bothered by the increasing size of her double chin as she aged. She has always had a shorter chin but as she had gotten older the ‘double chin’ appeared.

Under general anesthesia an initial small submental incision was made through which the neck was treated by liposuction removing about 12ccs of fat. The submental incision was extended to 1.5 cms and a 7mm thick curvilinear silicone chin implant was placed in a subperiosteal pocket on the bottom of the anterior chin bone. (the implant had no extended side wings)

Double Chin Correction result side view Dr Barry Eppley IndianapolisDouble Chin Correction result front view Dr Barry Eppley IndianapolisHer eight week postoperative result show elimination of the double chin and a much improved facial profile. Between the chin augmentation and the liposuction, it really takes at least six weeks after surgery to see the full benefits of the double chin correction procedures. Depending upon the degree of horizontal (and even vertical) chin deficiency, the chin deficiency may be better done using a sliding genioplasty for a more 3D chin augmentation effect. It also can have a more positive neck reshaping effect as it pulls the underlying neck muscles (roof of the neck) forward and up.

Highlights:

1) The double chin deformity is a combination of excess fat fullness under the chin and insufficient horizontal chin projection.

2) The combination of submental/neck liposuction and chin augmentation effectively treats the double chin deformity.

3) Whether the chin augmentation is best done by a chin implant or sliding genioplasty depends on the degree of horizontal chin deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sliding Genioplasty for Chin Implant Replacement

Monday, February 13th, 2017

 

Background: Chin implants in females is a common lower facial reshaping procedure. While they add desired amounts of horizontal projection and improve the facial profile, the extended wing designs of today’s chin implant designs can have adverse effects on they look in the front view. While the extensions on the implants are designed to create a natural transition into the jawline bone without a visible stepoff, they add chin width to do so. While this is rarely an issue in men, it can be more frequent aesthetic problem in women.

Women seeking an improved jawline have a different aesthetic goal than men. They do not necessarily seek an angular jawline with visible corners.  (some women may bit not the majority) Rather they usually desire a V-shape to their jawline with a smooth linear line from front to back. As part of that aesthetic goal the chin must be narrow and may even have a more pointy chin or smaller V-shape appearance. This is in contradiction to the look that many chin implant styles give to the augmented chin.

Case Study: This 35 year-old female had a prior history of having chin augmentation done using a Medpor chin implant of 6mm projection placed through an intraoral approach. She never liked the result as it gave her a wide and boxy chin. This did not fit her small petite face well. While it provided adequate horizontal projection, it made her chin too wide and too vertically long. She also developed some lower lip sag and excess tooth show.

Medpor Chin Implant Removal and Sliding Genioplasty Replacement intraop Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result front view Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia her indwelling Medpor chin implant was removed intraorally. To do so it had to be sectioned into multiple pieces and required the removal of 6 titanium screws. It was replaced by a sliding genioplasty that was brought forward 6mm and vertically shortened 3mms. A mentalis muscle resuspension and vestibuloplasty were performed to help with her lower lip sag. Concurrently, vertical lengthening jaw angle implants were placed through posterior vestibular intraoral incisions. The implants added 7mm of vertical length and 3mms of width.

Any form of chin or jawline augmentation must take into consideration the differences be tween male and female jawline shapes as well as the patient’s aesthetic goals. Even a ‘simple’ chin augmentation must take this into consideration as the operation may be a technical success but an aesthetic failure. (as this case illustrates) The entire jawline from front to back must also be considered in an effort to create an improved jawline that fits the patient’s face.

Highlights:

1) Chin implants in females create horizontal projection but often at the expense of too much chin width.

2) A sliding genioplasty can replace a chin implant by providing horizontal projection but with a more narrow chin width.

3) Jaw angle implants can create vertical lengthening with a sliding genioplasty to give a more defined jawline in females.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

Read More


Free Plastic Surgery Consultation

*required fields


Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits


Categories