Genioplasty revision or adding an implant? *with pics*

[chinquestions]

Hi all,

I had a sliding genioplasty performed about a year ago with 7-8mm horizontal and 3-4 mm vertical movement. While a marked improvement over my previously convex face, it still did not balance my lower 3rd from profile.

I have included before and after images to give everyone an idea of what I mean. Link is below:

https://imgur.com/a/dWXlvgU

As I would still like balance, this leaves me with three distinct options (and a fourth I mention at the end).

There is the first option, which would be just adding an off-the-shelf implant onto the genioplasty to span the final 4 to 5mm. Definitely the most cost effective, and the simplest surgery. I'm not sure if the hardware/stepoff will create issues with erosion/movement if the implant is not custom fitted to my face. 

That brings me to the second option-- a custom implant. I spoke to Dr. Y about this, and he believed that using a custom implant would be aesthetically superior, but didn't have much to say regarding the way it would fit over my altered chin, which I found surprising. He did think that some of the genio hardware would need to be removed for any sort of implant to fit.

The final option would be to have the genioplasty revised and pulled out further. I'm not sure if another 5mm is possible, but at least 3 to 4mm. There are drawbacks to this approach as well. Revision genioplasty is a more involved and invasive procedure with a longer, more miserable recovery. Additionally, my chin is narrow. Adding volume would aesthetically be preferable.

Technically, there is a fourth option. I know I got off lucky, so to speak. I didn't lose any lip form or function, I have no lasting numbness, and there is a substantial aesthetic improvement. Perfect being the enemy of good and all that. If I roll the dice again, who knows what could happen? I know a lot of people end up chasing revisions basically forever, and I'm not sure if that's a treadmill I want to get on. 

All thoughts, opinions, and experiences are welcome.

Thanks for reading!

[kavan]

Well, that was about the LIMIT of what a sliding genio can do to correct recessive CHIN. You can't really use a sliding genio to COMPENSATE for a recessive JAW. So, the doctor was WITHIN the aesthetic guidelines of what you can do with a sliding genio. Any more horizontal advancement from it would have resulted in the chin being too SHORT because the vertical (displacement vector) of a sliding genio is the UPWARD direction. So, no surprise here that it wouldn't balance your lower 1/3rd.

As to an implant, if you drop a straight vertical line from your lower lip, that is the farthest chin augmentation can go. Go further in any attempt to compensate for a mandible that is short in the profile direction, which yours is, and it can look weird (crescent moon deformity) But still, the chin should be somewhat BEHIND a vertical drop down from the lower lip especially when the mandible is 'short' in the PROFILE direction.

There is NO need for any revision genio for the above reason I mentioned in the first paragraph.

You have what they call a short 'throat distance' meaning the mandible, itself doesn't span forward enough in the profile direction. That dimensional aspect can only span more outward with a BSSO. Some people can have that as a single (lower jaw) surgery (with pre-surgical time in BRACES). Others might need double jaw surgery in the process.

So, my advice is to explore more options by consulting with a maxfax surgeon. When they give you a suggestion and take ceph X rays, you can relay the proposals to you back here to the board.

[chinquestions]

Hi Kavan,

Thanks for the informative reply.

I appreciate it.

I was concerned that to achieve the aesthetic goal that I had in mind, I would need some sort of jaw surgery.

I've seen some large 11-12mm genios that appeared decently natural (even a few on this board), but like you said, I think I would make a poor candidate for a revision based on the position of my jaw vs. the other patients in question.

That same logic would apply to an implant. Trying to cover jaw recession by moving the chin won't look any better even if chin width is preserved. I like the crescent moon analogy. I used Photoshop to see how stretching the chin pogonion to reach the vermilion border of the lips from profile would look, and I found the results to be uncanny and underwhelming, despite being more balanced. I know now that this is why, instead of merely being a result of my Photoshop skill limitations (or at least in addition to).

Regarding jaw surgery, I have no functional issues that necessitate it (I visited a few Maxfacs and got tested for sleep apnea, bite issues, TMJ, etc. while in the process of deciding on a genioplasty). It would be a purely aesthetic procedure.

Ultimately, it comes down to whether I feel that the aesthetic gain is worth BSSO as a best case scenario, and DJS at worst.

If that's the case, I don't honestly know if the substantially greater time/money involved is worth a comparatively smaller advancement.

In your opinion, would I be reaching the point of diminishing returns anyway regarding aesthetic improvement? I'm aware it's not a question that you can answer on my behalf, but you have a good sense of aesthetics so I'd be curious to hear your take.

[kavan]

Hi Kavan,

Thanks for the informative reply.

I appreciate it.

I was concerned that to achieve the aesthetic goal that I had in mind, I would need some sort of jaw surgery.

I've seen some large 11-12mm genios that appeared decently natural (even a few on this board), but like you said, I think I would make a poor candidate for a revision based on the position of my jaw vs. the other patients in question.

That same logic would apply to an implant. Trying to cover jaw recession by moving the chin won't look any better even if chin width is preserved. I like the crescent moon analogy. I used Photoshop to see how stretching the chin pogonion to reach the vermilion border of the lips from profile would look, and I found the results to be uncanny and underwhelming, despite being more balanced. I know now that this is why, instead of merely being a result of my Photoshop skill limitations (or at least in addition to).

Regarding jaw surgery, I have no functional issues that necessitate it (I visited a few Maxfacs and got tested for sleep apnea, bite issues, TMJ, etc. while in the process of deciding on a genioplasty). It would be a purely aesthetic procedure.

Ultimately, it comes down to whether I feel that the aesthetic gain is worth BSSO as a best case scenario, and DJS at worst.

If that's the case, I don't honestly know if the substantially greater time/money involved is worth a comparatively smaller advancement.

In your opinion, would I be reaching the point of diminishing returns anyway regarding aesthetic improvement? I'm aware it's not a question that you can answer on my behalf, but you have a good sense of aesthetics so I'd be curious to hear your take.

They do the maxfax surgery on an aesthetic basis only but usually pricey if CCW posterior downgraft is needed for the upper jaw surgery. Chance for single jaw. But those are things to explore. No diminishing returns IF they come up with a good plan. But, ya, could be pricey.

[chinquestions]

Hi Kavan,

That's good to hear, thanks. There are some excellent jaw surgeons in Florida that I can speak with about this.

Well, that was about the LIMIT of what a sliding genio can do to correct recessive CHIN. You can't really use a sliding genio to COMPENSATE for a recessive JAW. So, the doctor was WITHIN the aesthetic guidelines of what you can do with a sliding genio. Any more horizontal advancement from it would have resulted in the chin being too SHORT because the vertical (displacement vector) of a sliding genio is the UPWARD direction. So, no surprise here that it wouldn't balance your lower 1/3rd.

Also, I completely glossed over this on my first reading of your post. My apologies.

I used the term sliding genioplasty, but that was incorrect. Both the horizontal and the vertical dimension of my chin were advanced outward by 7-8mm and 3-4mm respectively. I've seen the term "down and out" used to describe this. My chin is vertically longer than it was before surgery.

Does this give me the option of revising the genioplasty to achieve further forward advancement, as the vector is not in the upward direction?

[Post bimax]

Hi Kavan,

That's good to hear, thanks. There are some excellent jaw surgeons in Florida that I can speak with about this.

Also, I completely glossed over this on my first reading of your post. My apologies.

I used the term sliding genioplasty, but that was incorrect. Both the horizontal and the vertical dimension of my chin were advanced outward by 7-8mm and 3-4mm respectively. I've seen the term "down and out" used to describe this. My chin is vertically longer than it was before surgery.

Does this give me the option of revising the genioplasty to achieve further forward advancement, as the vector is not in the upward direction?

Did they use some kind of buttress or graft between the gap?  I've been curious about this sort of genioplasty and how they are performed.  You should still be fine to have a revision.

[kavan]

Hi Kavan,

That's good to hear, thanks. There are some excellent jaw surgeons in Florida that I can speak with about this.

Also, I completely glossed over this on my first reading of your post. My apologies.

I used the term sliding genioplasty, but that was incorrect. Both the horizontal and the vertical dimension of my chin were advanced outward by 7-8mm and 3-4mm respectively. I've seen the term "down and out" used to describe this. My chin is vertically longer than it was before surgery.

Does this give me the option of revising the genioplasty to achieve further forward advancement, as the vector is not in the upward direction?

Oh, in that case, it's a good thing my closing advice was this:

So, my advice is to explore more options by consulting with a maxfax surgeon. When they give you a suggestion and take ceph X rays, you can relay the proposals to you back here to the board.

[eastcoastian1]

You have zero definition on your jaw line which is causing a large part of your issue.

If your bite is perfect, I'd honestly consider custom wrap around jaw implants. If not, really consider the jaw surgery route.

[chinquestions]

Hi all,

Thanks for the advice. I appreciate everyone stopping by.

As Kavan suggested, the next step will be to consult with a couple of semi-local surgeons for ideas and go from there.

You have zero definition on your jaw line which is causing a large part of your issue.

If your bite is perfect, I'd honestly consider custom wrap around jaw implants. If not, really consider the jaw surgery route.

My bite is juuuust about perfect. I'm not opposed to a custom wraparound, but I've also seen very few good results from them. If I were to do just the custom chin portion, I'm not sure how that would look with my jaw angles being what they are. Definitely food for thought, as I don't think jaw surgery will do much to define my jawline unless I'm mistaken.

Did they use some kind of buttress or graft between the gap?  I've been curious about this sort of genioplasty and how they are performed.  You should still be fine to have a revision.

They did not. I think if it the distance was a little larger, they probably would have used a graft. Pre-bent plates are typically used and then the bone fills itself in.

[tim06]

Hi all,

Thanks for the advice. I appreciate everyone stopping by.

As Kavan suggested, the next step will be to consult with a couple of semi-local surgeons for ideas and go from there.

My bite is juuuust about perfect. I'm not opposed to a custom wraparound, but I've also seen very few good results from them. If I were to do just the custom chin portion, I'm not sure how that would look with my jaw angles being what they are. Definitely food for thought, as I don't think jaw surgery will do much to define my jawline unless I'm mistaken.

They did not. I think if it the distance was a little larger, they probably would have used a graft. Pre-bent plates are typically used and then the bone fills itself in.

I am in exactly the same position as you currently, I got a genioplasty but my movement was 11mm and aesthetically it was basically the limit of what you could do without it looking like this:


I wouldn't consider your horizontal projection of the chin to be an issue, vertical projection as well as your mandibular angles aren't very well defined. 90% of the time we will see people either from the front, 3/4 or 1/3 which means your side profile doesn't matter as much as the look from the front. I am considering going for implants myself as that is the only thing you can do to address this.

[chinquestions]

Hi Tim06,

What kind of implants are you considering?

Just jaw angle, or a wraparound?

[GJ]

Tough call, but losing weight would help with the definition issue. Growing a nice, short beard would help with that, too.

My hunch is that trying to go with a larger genio would look strange in terms of the step off and overall an unnatural look. Definitely would not try that. Is your case worthy of jaw surgery? Borderline. If no functional problems, which is what I read, probably not.

For those of you who know a lot about chin wing (I know zero), is this guy a candidate?

[kavan]

Tough call, but losing weight would help with the definition issue. Growing a nice, short beard would help with that, too.

My hunch is that trying to go with a larger genio would look strange in terms of the step off and overall an unnatural look. Definitely would not try that. Is your case worthy of jaw surgery? Borderline. If no functional problems, which is what I read, probably not.

For those of you who know a lot about chin wing (I know zero), is this guy a candidate?

Theoretically, IF he had a 'virgin' chin. But he doesn't. Sometimes the chin wing doctors don't want to 'intersect' a prior cut with a chin wing cut because the direction of a chin wing cut is a different one than the direction of of a genio and his is most likely diagonal direction. Even when someone gets 2 chin wings, they cut ALONG the  first cut (use the SAME cut used prior) when they do another chin wing. However, he can probably get a revision of his prior genio via a cut through the SAME place ge got prior and have a bone buttress put in there. As long as he doesn't try to OVERCOMPENSATE for the jaw recession.

[chinquestions]

Tough call, but losing weight would help with the definition issue. Growing a nice, short beard would help with that, too.

Hi GJ,

I'm about 150 lbs in the pics and I'm 5'10". I just don't have much jaw definition unfortunately. I'm not sure if going any thinner would help. I also can't grow a beard, haha. Just unlucky on that front.

I'm not very knowledgeable regarding chin wing either, but from what I understand of it, the invasiveness is on par with BSSO and I don't think there are any U.S surgeons that routinely perform it (maybe Sinn does, not sure).

However, he can probably get a revision of his prior genio via a cut through the SAME place ge got prior and have a bone buttress put in there. As long as he doesn't try to OVERCOMPENSATE for the jaw recession.

The surgeon I spoke with today basically echoed this. He was also extremely adverse to the implant route, which I was a little surprised to hear.

[kavan]

Hi GJ,

I'm about 150 lbs in the pics and I'm 5'10". I just don't have much jaw definition unfortunately. I'm not sure if going any thinner would help. I also can't grow a beard, haha. Just unlucky on that front.

I'm not very knowledgeable regarding chin wing either, but from what I understand of it, the invasiveness is on par with BSSO and I don't think there are any U.S surgeons that routinely perform it (maybe Sinn does, not sure).

The surgeon I spoke with today basically echoed this. He was also extremely adverse to the implant route, which I was a little surprised to hear.

Well. Yes. Makes sense to me because that's the answer to revising; going through the same cut and adding a bone buttress.