Your Questions

Q: I am a male to female transsexual and need some facial changes as part of the process. My chin is too male looking with a prominent chin cleft and it is very wide. It is too wide and prominent for my face which i am trying to make more feminine and slender. I need my chin cleft removed and the width of the chin corrected by burring it down from inside the mouth.

A: In trying to achieve a more feminine looking chin, your aesthetic goals are correct but the method to get there is not the best way. Simple intraoral burring of the chin can only make a minimal narrowing effect and, if done aggressively, will like result in soft tissue sagging problems. The best approach to really narrow and taper the bony chin is through the use of an osteotomy. By doing a horizontal chin osteotomy, the downfractured segmented can be split in the middle and a center segment of chin bone removed. It can then be put back together with the entire chin significantly narrowed and with a much better tapered look to it. The chin soft tissues can then be better suspended with no risk of soft tissue sag (witch’s chin deformity) afterwards. This will also provide a better means of muscle tightening and soft tissue fill of the chin cleft to create a better chin cleft soft tissue reduction. While this sounds complicated, it is just a simple variation of the traditional chin osteotomy technique. (genioplasty without the side)

Dr. Barry Eppley

Indianapolis Indiana

Q: Dear Dr Eppley, I underwent a chin reduction with a jaw contouring operation about one year ago. As for the result, have always found that it looked odd. My chin was reduced by 1cm and now my mouth does not close properly at rest and there is a ‘balling’ shape to the muscle and a wrinkled look. I recently had a MACS lift as my jaw muscles also looked slack after the op. However my chin is unchanged and still feels loose, unattached and ‘balled up’. I have come across your writing online and think your expertise may help resolve this. What do you suggest?

A: If your chin reduction was done through an intraoral vertical osteotomy reduction technique, then you would likely end up with soft tissue excess over the chin area when a large amount (1 cm) is vertically reduced.. (mentalis muscle and skin) These excess soft tissues could very well end up looking like a ‘ball’ over the chin area. This could really be predicted beforehand as where is all of the soft tissue that covered the 1 cm that was removed supposed to go?

No form of a facelift would solve the excess tissue problems in the chin area nor should it be expected to. A MACS lift, like any form of a limited facelift, is a lateral or side of the face operation based on soft tissue pull. So it will tighten up any loose skin over the side of the jaw/jaw angle area/jowls, but will do nothing for the chin area. The chin area excess is a central problem that requires direct excision and tightening, most commonly done through a submental incisional technique.

Dr. Barry Eppley

Indianapolis Indiana

Q: Is it possible to have a vertical chin that points downward as a result of fleshy tissue and not bone? My chin is vertically too long for my face and projects downward especially when I smile. I’d hate to have complications from having the bone burred down on the tip but would also hate to have titanium plates & screws in my chin from a wedge of bone being cut out to reduce the chin. I live in Texas and I don’t’ know any surgeons here that are properly certified and experienced in chin reductions. Please let me know. Thanks.

A: A long vertical chin can be the result of too much bone, too much soft tissue, or a combination of both. In most cases, vertical chin excess is a combination of both. By definition, a chin that is too long because of bone must have extra soft tissue to go with it. Making the proper diagnosis helps one correct the right chin reduction procedure. Not properly addressing the right problem, or inadequately treating it, is the reason so many chin reductions have unsatisfactory results.

A physical exam can usually tell which component make up the vertically excessive chin. In some cases, a simple panorex dental x-ray can also be helpful. The observation that your chin soft tissues pull downward when you smile is common and indicates that it a combined bone and soft tissue problem.

Chin reductions can be done by bone only reductions (intraoral horizontal reduction osteotomy) and bone and soft tissue reductions. (extraoral submental bone burring reduction and soft tissue resection and tightening) Because these two procedures are so different, one can see the importance of making the correct diagnosis of excessive tissues.

Dr. Barry Eppley

Indianapolis Indiana

Q: I had a chin reduction just about two months ago. I still have not seen any results. If anything I feel  that my chin seems longer then before. I spoke to the doctor about it and addressed my concerns. He said it takes up to 6 months for the final results. If by then I am not happy with it,  he will then try something else. What to you suggest?

A: There is no question that any form of chin surgery takes time for the swelling to go down. In my experience in chin reduction, this is particularly true as swelling will mask a reduction longer than it will an augmentation. (the result from a chin augmentation will be seen immediately, the issue is that it initially looks too big due to the swelling) The initial soft tissue swelling from most forms of chin reduction will make it look longer or bigger initially and this is normal. Generally, however, the results start to become apparent within three to four weeks at most. By six weeks, patients should be able to say that they see a difference if not significantly so. It will take three to six months, however, for the true final result to be appreciated.

One important factor that controls the amount and duration of swelling is what type of chin reduction procedure was performed. There are two different types of chin bone reduction procedures, an osteotomy and a burring or shaving. One is done from inside the mouth (osteotomy) and the other is done from an incision underneath the chin. Knowing which one was done can help determine how long it may take to see the final results from the chin modification.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Where to start? I had a chin reduction at a hospital overseas in 1992. I have never been happy with it. I have always been so self conscious that it looks odd to people when they see me from certain angles. I also felt that it was too extreme and not what I had pictured the result would look like. I also have a metalplate in my chin and too much fatty tissue in the front chin area. Is it possible to have the chin operation redone so it looks better? Or is a chin implant the answer for me?

A:  Chin reductions can create unhappy results if not done properly. When you reduce bony support, you have to account for the overlying soft tissue. Reducing bone requires stripping off all of the chin pad tissues, there must be a way to satisfactorily reattach it and reduce or tighten these soft tissues. If not done, the chin bag will sag down and look like a lump of fatty tissue. Doing a chin reduction without simultaneous soft tissue management is akin to doing a breast reduction but without reducing and tightening the loose overlying skin.

There are three approaches to managing a sagging or ptotic chin pad. They include an intraoral muscle resuspension, a submental chin tuck-up, and the placement of a chin implant. Which approach is best depends on how on much the chin pad sags and one’s facial profile and appearance.  If one is happy with their profile (chin not deficient), then either a muscle suspension or a submental tuck-up will work. The difference between the two depends on much tissue there is to tighten and whether one can accept a scar under the chin. If one feels that their horizontal chin position is short, then a chin implant would be preferable.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I would like information on the horizontal chin reduction procedure.  My chin juts forward to a point (witches chin) and I think it being reduced would really help my appearance.  Most interested in knowing how the procedure is done, down time needed for recovery, surgery location (outpatient in center or hospital, or in physician’s office),  and rates of success.

A: A big chin (macrogenia) can be either too far forward (horizontal excess), too long (vertical excess) or a combination of both. Determining the 3-D dimensions of what makes the chin too big is important as it can change the method by which the chin is reduced.

Horizontal chin excess is best reduced through a submental (under the chin) incision rather than from inside the mouth. This is because it is important to properly manage the soft tissue excess which will result once some of the bone support is removed. If the soft tissues are not removed and tightened, one will end up with what is known as a witch’s chin deformity. (exactly the appearance of what you wanted to improve in the first place!)

The chin is horizontally reduced by burring down its prominence and tapering the bone into the sides of the chin. The mentalis muscle is brought down over the underside of the reshaped chin and any excess removed as it is re-attached to the its fellow muscle. Likewise, redundant skin and fat are removed so that the chin soft tissues are nice and tight.

Chin reduction surgery is done as an outpatient surgery under general anesthesia. It takes about an hour to perform. The chin is taped and will be sore but there are no restrictions after surgery. It takes about 3 weeks for the chin swelling to largely go away and it begins to feel normal again. The success rate is 100% in terms of having less horizontal projection. The usual amount of actual horizontal chin reduction  that is achieved is from 5 to 8mms.

Dr. Barry Eppley