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A full or fat neck is most commonly treated by liposuction, particularly if one is fairly young. The results from neck liposuction are significantly influenced by the quality of the overlying skin. Good taut or thick skin will respond by shrinking and adapting upward to a less obtuse neck-jaw angle. Loose or inelastic skin may shrink somewhat but it will be irregular with band and cords apparent to the eye. When neck skin is loose, the liposuction procedure must be combined with some type of facelifting procedure. Whether it is more of a limited or full facelift will depend on how much loose skin exists.
One often overlooked consideration in neck liposuction is that of the chin. Should the chin be brought forward or is its projection adequate where it is currently? In the spirit of what one is trying to achieve by removing fat from the neck…a more evident jaw and neck line…the chin should not be forgotten. In some cases, it can be a good complement to the look that liposuction creates.
One effect that neck liposuction does create is the illusion that the chin is a little more prominent. As the neck-jaw angle, technically known as the cervicomental angle, become less obtuse and positioned back somewhat, it can look like the chin is a little more prominent. That is easy to understand as the chin may look more forward because the neck has moved back. In some cases, changing the shape of the neck may be all that is needed to improve what one thinks is a short chin.
In other cases, neck liposuction should really be combined with a chin implant. The problem is not just too much fat in the neck but the chin is really short as well. This is a much more prevalent issue in men than it is in women. Men can aesthetically tolerate a more prominent chin anyway, women must be more careful about de-feminizing their appearance. A combined neck liposuction-chin implant procedure is a classic ‘ying-yang’ facial procedure where movements in opposite direction create a better overall effect than either one alone.
Whether a chin augmentation is an additive benefit to neck liposuction can be determined easily prior to any surgery with computer imaging. Imaging profile structures, where the skin is in contract to the background, is very accurate and predictive of what surgery can really achieve. One can have themselves imaged with neck liposuction alone, combined with a small chin implant, and then combined with a larger chin implant as well. Looking at all three changes can really help one decide what is best for themselves.
The shape and appearance of the neck is partially influenced by the forward position of the chin. In many ways, the chin is an extension of the horizontal vector of the neck. As with any neck reshaping procedure, the chin should not be forgotten in surgical consideration and planning
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
1. How do I know a chin augmentation will make my face look better?
One of the important elements in improving facial attractiveness is balance and proportion. Chin augmentation is about improving the proportions of the lower face in both horizontal (lateral view) and vertical (frontal view) dimensions. The beauty of chin surgery is that it can be visualized very accurately before having surgery through computer imaging. Morphing the profile of the chin in all dimensions can be quickly and easily done since it is a facial prominence that is isolated like a projecting rock from a cliff. While you or your plastic surgeon may feel that chin augmentation would be beneficial, the guess work can be taken out of that consideration by imaging of your photographs.
2. What are chin implants made of?
By far, most of the chin implants used are made of silicone rubber, also known as silastic. This inert material is one of the most biocompatible of allbiomnaterials, is made in dozens of different shapes and sizes, and is inexpensive. Other implant materials are also used of which Medpor (polyethylene) is the most well known. It is a porous plastic material that is stiffer (needs a bigger incision to insert)and more expensive. Rarely used are other materials including Gore-tex and Mersilene mesh.
Given these different implant options, patients often ask which one is best. While certain plastic surgeons may advocate one over the other, the body does not really see them as any different. The shape or type of chin implant used is by far more important than the material from it is made. Given that today’s implants can change numerous dimensions of the chin, one should focus on these change possibilities and how they may be aesthetically beneficial.
3. What is the best way to place a chin implant, through the mouth or from under the chin?
Chin implants can be introduced through an incision inside the mouth behind the lower lip (vestibular) or through the skin from under the chin. (submental) While either approach will work, the submental incision is best in most cases for several reasons. First and foremost, this approach does not disrupt the superior insertion of the mentalis muscle so there is no risk of a chin sag afterwards. Secondly, there is no risk of the implant moving higher up on the chin bone since the upward end of the pocket stays naturally lower when made from below. Lastly, there tends to be less pain afterwards as the pocket dissection does need to be as big to get the implant in place.
4. Will I be able to eat and drink right after surgery?
Yes. Since the chin implant is on the front end of the jaw bone (mandible),it is does not interfere with jaw movement or opening one’s mouth. It is also places no restriction on chewing or swallowing. If an incision is used from inside the mouth, I merely tell patients not to bite food off but to use utensils to bypass what your front teeth normally do When the incision is used from under the chin, there are no restrictions at all
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5. I heard that the chin bone can be cut and moved forward (osteotomy) instead of an implant. Which is better?
Another well known method of chin augmentation is to move the chin bone forward rather than using a synthetic implant. While much less commonly performed than an implant, an osteotomy can be a good option for the right patient. Since it is a ‘bigger’ operation that takes longer to do and incurs more expense, proper patient selection is critical.
In my Indianapolis plastic surgery practice, I use the following three indications for a chin osteotomy. A young patient, the need for significant horizontal advancement, and if one is undergoing facial bone movements (orthognathic surgery)at the same time. The value of a chin osteotomy is that it can avoid a large implant that must remain complication-free over a long patient life-time.
A chin osteotomy can also do one thing that an implant can not. It can lengthen the chin vertically. While minor amounts of vertical height increase can be obtained by a low position of an implant, significant lengthening requires an interpositional graft after the chin segment is brought downward.
6. Can a chin augmentation be done with other facial procedures at the same time?
Yes. In fact, most chin augmentation procedures are usually part of combination facial plastic surgery. Most commonly, chin enhancement is done with rhinoplasty in a young patient and with a facelift in older patients. It is also one of the procedures in the facial ‘trifecta’ for men…chin, cheek, and jaw angle augmentation.
7. If I play sports, will having a chin implant be a problem?
The risk of getting hit in the chin is a common one in many types of sporting activities. Trauma to a chin implant will not cause it to break or fracture but it may move it shift or move out of place. For this reason, I prefer to place a screw to secure it into place in younger male patients who participate in any form of contact sports.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Plastic Surgery Case Study: Chin Implant Replacement - New Implant or Osteotomy?
Author: barryeppleyBackground: Like all surgical implants used in the body, chin implants do have some long-term effects. This is particularly true when they are used improperly or are inadequately positioned.
This is an interesting case of a 50 year-old female with the desire to improve her chin position. She had suffered with a short chin her entire life. But she had a history of having had a rhinoplasty and a chin implant in another country when she was 21 years of age. Despite this early surgery providing some improvement, she was still never really satisfied.
Because she was currently in orthodontics for teeth straightening (more older people are doing it than ever before, I have even see a 65 year-old in braces!), a lateral cephalometric x-ray was available for review. It clearly shows a small chin implant that is positioned above the most anterior point of the bone. The implant has eroded into the bone by about 50%, exhibiting a well-described phenomenon known as implant-related ‘pressure resorption’.
Her surgical options were to remove and replace her old implant with either a new larger one in a better position or to move the chin forward (advancement osteotomy) after implant removal. While either approach is a better option than what she had, the amount of chin advancement that she needed made a bone-based operation the best choice. (it could move the chin the furthest forward without using a lot of foreign-material to do it)
The operation was performed through an intraoral approach. The old chin implant was found exactly where the x-ray showed it to be, on the bone at the level of the labiomental crease significantly above where it should ideally be placed. It has settled into the bone over time from the pressure of the overlying soft tissues.
The implant was removed and a horizontal chin osteotomy was performed. The chin bone was brought forward as much as possible, keeping the back edge of the chin bone against the front edge of the bone above the moved segment. It was plated into this new position with a specially-designed chin plate with a built-in movement of 12mms forward.
While a bigger advancement could have been tolerated, the aesthetic change was a big improvement. It would have been possible to enhance the advancement even further by placing an implant in front of the osteotomized chin bone. When done together, I call this procedure an ‘extreme chin augmentation’.
Case Highlights:
1) In cases of severe chin shortness, a large implant over time will eventually settle some amount into the underlying bone.
2) Chin implants placed through the mouth can move upward from their desired position on the pogonion. This can be avoided by screwing them into position.
3) When the chin deficiency is large (> 10mms), it may be better to consider a chin osteotomy long-term rather than an implant in some cases.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Chin augmentation has been a procedure that has a near seventy-five year history of being done in humans. It remains as a fairly simple and highly effective method for improving the most prominent area of the lower third of the face. Many different materials have been used to serve as a chin implant but synthetic technology accounts for most augmentations due to their ease of use, low cost, and long-term stability of the result.
For patients considering chin augmentation, there are three considerations one should ponder. While many plastic surgeons have their preferred methods, usually with good reasons, patients today are better educated and can participate more fully in preoperative planning.
The first consideration is that of the choice of implant material. Vulcanization technology has allowed for silicone rubber (silastic) to long be the only material of choice. Silicone chin implants are the least expensive and the most flexible and they can be inserted through the smallest of incisions. Medpor (polyethylene) and polytetrafluoroethylene (PTFE or Gore-Tex) are more recent chin implant materials who have a long history in many other types of surgical implants. Medpor is fairly stiff (needs bigger incisions to insert) and is porous, which in theory offers some biologic advantages. (vascular ingrowth) PTFE is softer than even silicone with some limited porosity on its surface.
The different chemical compositions and properties of the implant materials may seem confusing. But in my opinion, they are no proven biologic advantages to any of the implant materials. They all will work. The body still sees them as a well-tolerated foreign body which becomes encapsulated. The important differences between them, in my opinion, relates to the second consideration….what different styles, shapes, and sizes do the various manufacturers offer. Chin augmentation today can create a wide variety of geometric changes to this part of the lower jaw… from round to square, central to more lateral projections, to even include the creation of a chin cleft or dimple. Think about your chin shape carefully and how it will affect your overall facial shape. What shape does it have now and what would you like it to become? Do you want a more sculpted and more defined facial look? Do you want to overcome a larger nose and a shorter neck? Do you want it to look more masculine or feminine? Many implant styles and sizes exist. Consult carefully with your plastic surgeon to get the look you are after that best fits your face.
Lastly, what insertion route for the implant do you prefer? They can be placed through an incision under the chin (submental) or through the inside of the mouth. (vestibular) Each has its own advantages and disadvantages. In the right hands, either approach can work successfully. The most versatile and least prone to potential problems is the submental approach. Many patients worry about the potential scar but that is an unnecessary concern. Coming from below has the advantages of getting the implant down at the inferior edge of the bone, permits easy screw insertion if desired, and allows neck liposuction or submentoplasty to be performed through the same incision. The submental approach is also associated with the least potential for mentalis muscle dysfunction and lower lip incompetence.
Chin augmentation today offers subtle but important aesthetic options for patients to consider. There is no one single way or one implant that is better than another. Consult with a plastic surgeon who is well versed with the different materials and approaches so you are not getting just the ‘standard approach’, but a chin augmentation surgery that has been designed for you.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
I frequently get e-mailed and asked…’What can I do to get a stronger jawline?’ This is exclusively a male question and usually, but not always, is from a younger patient. In looking at a lot of photographs of male patients with this concern, the most common problem is that the chin is short and the jawline is ill-defined. Some cases are more severe while others are much more mild. In either case, the strong jawline of male models and some famous male actors has set a beauty standard for males to aspire to.
In making a jawline more distinctive, there are three areas to consider improving or highlighting. Anterior projection (chin), posterior lateral width (jaw angle) and inferior border or circumferential jawline are the areas that can be surgically augmented with implants. Other than the chin, there are no bony moving or bone grafting procedures that will work.
From a practical standpoint, the two most common and easiest implants to place are the chin and jaw angle. The available implants are well made with numerous styles (chin) and a good range of sizes that will fit all but the very largest, or most bony deficient, patients. By bringing the chin forward (and more square) and making the back of the jaw (jaw angle) wider, the jawline becomes much more distinctive. This approach will work for the vast majority of male patients.
The use of a chin and jaw angle implant for jawline augmentation does leave a gap in the body of the mandible between the two. Depending upon the type of chin implant used (how far back the wings of the chin implant goes), that gap can be up to several cms. in length. While this may seem unfavorable, it is usually not discernible and the aesthetic benefits of considering ‘filling in that gap’ are not usually worth it in my Indianapolis plastic surgery experience. Having three separate implants (five actually along the entire jaw) is bound to have some irregularities that certainly will be felt.
Implants for the body (middle) of the jaw are not commercially available. No such stock implants exist. That fact should tell you that their need, or more pertinently their importance, is really quite limited. To use such an implant, it has to be hand-carved during surgery. Actually this is not that difficult as the use of Gore-tex blocks or sheets can be easily used and shaped. I have no qualms about the ability to shape or place them but my concerns revolve around the ability to feel them, particularly the transition with the chin implant on the front edge and the jaws angle implant on the back edge. Because of these concerns, there has to be a really compelling reason to use them.
There is an alternative to a piece-meal implant approach to total mandibular augmentation. A one-piece custom implant can be fabricated before surgery off of a 3-D CT mandibular scan of the patient. This is best used when the objective is vertical lengthening of the jawline as this is how it must be placed. It can not be used to provide posterior width like a traditional jaw angle implant.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Chin augmentation is a popular procedure for bringing out the prominence of the lower third of the face. It can have a powerful effect on the facial profile, particularly in men. Most commonly, the chin is brought forward in a horizontal direction elongating the jawline and improving the look of the neck angle which lies underneath.
Chin augmentation can be done by two completely different methods and is the only facial area which can be enhanced by such diametric approaches. By far, the placement of a chin implant on top of the bone makes up how it is done by most plastic surgeons. Using a variety of different implant options, the chin can be quickly and reliably brought forward in similar dimensions and shape of the implant selected. Conversely moving the chin bone, known as an osteoplastic genioplasty, can also be done to create a similar effect. Cutting the bone is technically more involved and takes longer, but in experienced hands is just as reliable as an implant.
These two chin surgery methods have their proponents and the merits of each have been debated for years in plastic surgery circles. Chin implants are usually preferred because of their ease of placement and ‘easier’ recovery. But the choice of either approach should not be based on what is easiest but what is most anatomically correct and will have the least long-term risk of complications. Each has its own place in the properly selected patient.
For small to moderate amounts of horizontal advancement, regardless of patient age, the advantages of a chin implant makes it an easy choice. Moving the chin bone for the sake of 5mms or less of movement is not worth the greater complexity of the procedure or its increased risk and costs. When the amount of chin advancement starts to get closer to 8 and 10mms, the consideration of an osteotomy starts to be a good consideration. This is particularly poignant in the younger patient in their teens and twenties. Large chin implants over a long lifetime are not without some risk of eventual problems.
What may tip the balance for an osteotomy over an implant is if there is a vertical dimension issue along with being horizontally short. While an implant can bring the chin forward, it can not obviously shorten it. Shortening a long chin can only be done by removing a wedge of bone with an advancement osteotomy. Conversely, however, an implant can lengthen a chin somewhat as it brings it forward. By positioning and securing the implant on the lowest edge of the bone, a few millimeters of vertical height can also be obtained. But more significant lengthening is best done by osteotomy where the whole chin complex and its attached soft tissue are brought down with it. This makes the vertical change in the chin more natural and physiologic.
This being said…which is better…implant or osteotomy? The answer is the blending of the considerations of patient age, the dimensions of the chin deficiency, and one’s tolerance of the amount of physical recovery. Large horizontal deficiencies, vertical changes that are needed, and a young age make the osteotomy preferred over the more commonly used method of implant augmentation.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
A facelift primarily provides a rejuvenative effect along the neck and jaw line. By removing neck fat, tightening the platysma muscle, and removing excess skin back and up towards the ears, a more defined neck angle is created. Such changes are largely seen in the profile or three-quarter view which is how we are viewed by most other people.
One technique to enhance the change in the neck angle is to lengthen the jaw line at the same time as the facelift. This is most commonly and easily done with a chin implant. By bringing the point of chin projection further forward, the length of the jaw line becomes more pronounced and the neck angle looks even better. It is surprising on photographic analysis how many women are slightly chin deficient by classic profile analysis. When one is younger, a mild chin deficiency adds to a juvenile appearance. When one is older, however, the reverse is true and it makes one look older and more frail.
Placing a chin implant in most facelifts involves no additional incisions. In a full facelift, a submental crease incision is used for the midline neck work. By going north instead of south, the end of the chin bone is easily found. Dissection and implant placement is quick and simple with little extra operative time.
A legitimate concern for many patients is that the fear that the implant may be too big. This can be avoided by doing a preoperative profile prediction analysis . (which is standard in my Indianapolis plastic surgery practice) This not only helps identify whether a chin implant may be beneficial to one’s facelift results but provides a good feel for what size it should be.
Facelifts and chin implants are a common combination for many female facelifts and much less commonly so for men. A slightly stronger chin and defined jaw line creates a more youthful appearance and should be considered as part of the overall facial rejuvenation strategy. Some plastic surgeons debate about what type of chin implant is best to use. I think the material choice is irrelevant as long as gthe plastic surgeon is familiar with its handling.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
There is no doubting the influence that a strong jawline has on the appearance of the male face. From a well-defined chin back to the jaw angle, a straight and strong jawline creates a favorable lower third of the face which is aesthetically important in men. But creating a good jawline for those who don’t have one is not as simple as it may seem.
What makes up the jawline? It is a single bone of the mandible (lower jaw) that incorporates three distinct aesthetic regions. These include the chin, the body, and the jaw angles. The combination of all three ideally create a well-defined line (at the lower border of the jaw) that runs smoothly from the chin back to the jaw angle. It is broken up into three areas based on how it must be surgically approached. The use of chin implants for the front and jaw angle implants for the back are well known. But it is the central zone, the body, that poses the most challenging area to aesthetically augment.
If the body area is augmented with an implant, this poses three potential problems. First, there is no standard implant that is available or pre-fabricated for this application. As a result, one has to custom carve during surgery the shape and length of implant needed. Secondly, placing a body implant in between a chin or jaw angle implant creates a three-piece jawline implant that has the real potential of being able to feel the transition zones between them. This is particularly true at the back end of a chin implant and the front end of the body implant. Lastly, the purpose of most jaw body implants is to provide more projection to the edge or bottom side of the jawline. This makes placing it and holding it in place after surgery a potential challenge.
For these reasons, I feel that a custom fabricated one-piece jawline implant is almost always best. This requires preoperative modeling and an implant design which certainly adds to the cost of the operation. But if one is looking for a more vertical elongation to the entire jawline, this is definitely the way to go. One-piece implants, regardless of size, are always easier to place and will have less potential for postoperative problems.
When lateral jawline augmentation is desired, then the three-piece approach is more reasonable. The body and jaw angle implants can be placed inside the mouth while the chin implant is placed through an incision underneath the chin. Screw fixation is used for all implants as this is best way to prevent shifting or migration of the implant.
Every jawline patient must be looked at individually and a specific implant approach used for each depending upon their goals and aesthetic desires. The concept of jawline augmentation with multiple plastic surgery options intermingles a variety of factors that defies one standard approach.
For the older male, creating a stronger jawline must take into account the development of jowling from aging and gravity. A facelift (neck-jowl lift) would be a necessary part of the plan. The use of one or two implants, at the chin and jaw angle, may be all that is needed to recreate a more well-defined jawline prominence.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Revision of Problematic Chin Implants and Soft Tissue Problems of the Chin
Author: barryeppley
Chin augmentation with an implant is a common and relatively simple operation in most cases. However like all plastic surgery procedures that require an implant to create much of the result, implant-related complications can occur. These complications can include inadequate to oversizing of the implant, infection, and shifting and malposition of the implant. Many chin implant problems can be solved by simple revisions such as adjusting the implant’s position or changing the implant’s size or shape.
One chin implant problem that poses a more difficult problem is fixing an implant that is too big or one that has to be removed in its entirety. Or the appearance of the chin after an implant has already been removed, known as a ‘witch’s chin’ deformity. The expanded soft tissues of the chin will not simply shrink back down and be like they were before the implant was ever placed. Just like removing a breast implant, the overlying expanded skin will sag after the support of the implant is lost.
Management of the soft tissues of the chin from implant expansion can be dealt with in several ways. If the augmentation of the original chin implant is still desired (but an implant is not), then the bone of the chin can be moved forward in a procedure known as an osteoplastic genioplasty. The forward movement of the bone will serve the same purpose as the implant and will ‘re-expand’ the soft tissue envelope of the chin. The mentalis muscle can also be further tightened from the inside of the mouth where this operation is performed. If the implant is not going to be replaced or was removed previously (and no new implant is desired), then the skin and muscle must be retightened. This is done using the original incision underneath the chin (or a new one must be made if the the chin implant was put in from inside the mouth) The loose muscle and skin is removed and tightened from below. This technique will prevent chin tissue sag after a chin implant is removed or will correct the witch’s chin deformity that exists from a prior chin implant removal.
In some cases, it may be possible to lift and tighten the sagging chin tissues from inside the mouth. This technique requires special suture-bone anchors or screws placed into the bone onto which sutures can be used to hold the new position of the lifted chin muscle.
Revision of shin implants requires knowledge and skill at performing a variety of chin procedures including moving the bone and methods to resuspend and retighten loose chin tissues.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Making a face more square or angular can be done through bone augmentation, fat reduction, or both. I have found that there are two types of patients who come because they want a more defined facial look. First is the male patient (usually younger)who does not necessarily have a full or fat face but wants more definition at the defining points of the face. In some cases, I call this seeking the ‘male model look’. The second type of patient is male or female who does have a fuller face and simply wants to be ‘less round’. Their goals are not quite so precise as the first patient. Usually they are younger as well but can be middle-aged also.
The defining bony points of the face are the cheeks, chin, and jaw angles. Facial fat points are the cheeks and neck. Those searching for the ‘male model look’ are usually looking at the trio or combination of cheek, chin and jaw angle implants. The thinner the face is, the more profound the result will be with this triple implant approach. When you are placing three implants, or simultaneously changing three facial prominences, it is always best to not to overdo it. Large implants in all three places can create a very unnatural or artificial look. Cheek implants never look too good if they are too large. Subtle cheek changes are more natural.The proper size of a chin implant is easier to know because the amount of chin deficiency can be measured in profile. Most men should consider a more square chin implant style as that is often what this type of patient is trying to achieve. Jaw angle implants can rarely be too large as they are manufactured small anyway and the jaw muscles and thickness of tissue over the jaw angles can camouflage a great deal of the implant.
Those trying to deround a face must use a different approach. Fat removal in the neck (liposuction) and in the cheeks (buccal lipectomies) are an important element of derounding and is often done with a chin implant. In rare cases, cheek implants may be considered but they should be small as buccal fat removal will create the visual impression of some minor cheek augmentation as the area below the cheek moves inward. This type of facial derounding is more subtle than squaring a face with the most dramatic changes occurring in the neck and less in the cheek and side areas of the face.
Careful analysis of the face prior to surgery through computer imaging can be invaluable in this type of surgery. Changing multiple areas of the face at one time, with the objective of changing one’s facial look, requires good insight and understanding between the patient and their plastic surgeon.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis