LAM FACIAL PLASTICS

Hi Dr Lam.

I had chin implant 2 years ago (silicon), with same method you use (subperiosteal pockets for the wings and central chin component above the periosteum. When I awoke from surgery the left aspect of the chin and entire left wing was above the jawline. I was reassured by my surgeon this was swelling alone. Being a medical specialist I took this with a grain of salt and hoped for the best. My suspicions were correct. When the swelling had truly settled its position was confirmed. After about 8 months I had revision surgery by the same surgeon. I asked to have it lowered on the left to match the right (which is in excellent position), and a titanium screw to keep it in place.
Not too happy with the outcome. The surgeon lowered the left chin aspect and put a screw there making my chin even, but the left wing position he basically left in the original position above the jaw line saying "I thought you'd be happy with this" and "I have an uneven chin". The latter is true but very minor, and I accept you can only place an implant on what you've got. I don't accept that because the left jaw is very minorly hypoplastic with respect to the right that the implant will by default be malpositioned. To me it is an error of technique or more importantly in my surgeons case I think "too hard to fix easily". Well having a surgeon that doesn't listen/can't be bothered or whatever, is too much. Not going back there even though I am sure he would give me "mates rates" for a further attempt at correction. The left wing tip is about 10mm above the jaw line with the implant sloped from the left chin superiorly as it moves posteriorly. It bugs me visually (my family can't notice it) but more importantly I can feel it and it does ache occasionally. As the most wing tip overlies the roots of my teeth, I am concerned about erosion long term.
I am based in Australia, and have yet to meet a surgeon here I am confident in after my experience. I am happy to travel to someone with appropriate expertise. I assume my implant can be corrected? Do you ever use screws to keep an implant in position?
Thanks for your input.
J

first i am sorry to hear of your situation. there are a few things to keep in mind:
1. an implant pocket that is made 1 cm above another one could be fixed possibly easily or possibly with difficulty because the adjacent pocket might be right next to it and it may communicate with it. i do not use screws just the pockets to hold things in place.
2. i always say, "i don't treat feel i treat look". that is so important. if you can't really see it but just feel it then the risk of another surgery may not be worth it. i set up for my chin implant patients before surgery that they may feel something off afterward but they should not see it. no matter how precise we are as surgeons, areas may not be perfect in terms of symmetry. oftentimes chin implants fit differently on each side because the mandible is shaped differently.
3. typically, but i cannot guarantee this, 1 cm above the mandible in the center (or midline) too high generally could be pretty safe but is getting closer to not being as ideal in terms of pressure on dental roots. along the wings, there typically is not very much pressure of the implant on anything because it is typically very tapered and not pushing on the bone. however, i do not know your situation nor the exact implant so that is something you need to talk with a surgeon in person with an perhaps an xray may help you determine what is going on with both implant position and bony changes.
4. sometimes when we have a bad relationship with a surgeon, it colors our judgment. i talk about forgiving yourself for having picked this surgeon and to a lesser degree forgiving the surgeon. i have too many patients come to me for revision surgery but the revision oftentimes needs to start in the heart. they are so angry or sad about a previous situation that they will do anything to fix it. what they need to fix is their heart and mind first. sometimes just wanting to fix something relates to the fact that they just want to get rid of that previous bad experience with a surgeon and will do anything even take risk to do so. that may not be the case in your situation but it could be a part of it. my feeling is to start there and get clean so that you can make a clean decision about revision work.
hope some of those ideas help to start.
best,
sml

Thanks very much for your thoughtful input Dr. Lam.

Hopefully I can ask a few more questions and add a few more comments if you will indulge me?
1) In relation to your last point- forgiveness. Excellent point. I have made sure I don't act on anger and I won't be making any rash decisions given it is my face and appearance on the line. I think I have a sufficiently long cool off period. I have become accustomed to my new look. I am unhappy with the asymmetry that is present. My wife says she can't notice but to me it is obvious. I want the implant correctly positioned not only for the fact it is "uncomfortable and occasionally painful-(eg in the cold on that side)", but also it looks wrong- essentially I have two jaw lines on one side. I'll post a photo if I may.
2) I am concerned that a new pocket will communicate with the present one. I know it will in part. The proximal left wing close to the chin is mobile- I can move it down a good 5-8mm onto the jaw line so clearly the sub-periosteal pocket is abnormally large. It is only the most lateral left wing tip which is fixed and immobile well above the jawline and at the left of centre chin proper where there is a screw. I am concerned that if a new pocket is made without screw fixation the implant will migrate north. I know it is a long shot but can the wing be plied out (given the rubbery nature of the implant) without the screw being removed before placement in the new tunnel? If that is a no go option what, if any, measures do you use to correctly maintain position other than the periosteal tunnel?

Thanks once again and forgive my multiple questions. I don't want to be a pain, but I want to get results. Normally its me thats doing the treating now I feel somewhat helpless and at the mercy of others. Doctors, especially in private, tend to me more motivated by money than patients (of course not universally true) and finding the right facial surgeon seems near impossible. It has given me a new sense of the patients perspective trying to get appropriate answers and navigating ones way past multiple obstacles ...
I get the impression you care which is most refreshing and really appreciate your insight.

regards

J

1. glad you are working on forgiveness and those thoughts. it is something that is important for me to offer a holistic approach. sometimes we notice things more than others because of a past legacy that goes beyond mere forgiveness but simply colors our perception. i had a gentleman that i did a chin implant revision on and the implant was so high up it was eating through his dental roots. that was worth it, i.e., to do the revision. one thing i would suggest no matter what you do is to start with an xray to see where the implant is. i would be more motivated to perform a correction if there was something functionally wrong with your implant than if there was a small cosmetic correction needed. sometimes i fix something that may be minor or not so minor and i don't deliver or make it worse. that would be really bad so i would rather have you take the right steps for this. as far as pain is concerned, i have no idea why that is. again, an xray may indicate if it pressing on the mental canal or some other structure. if not, then that is a good sign. i just need more info to feel comfortable moving forward.
2. i do quite a few chin implants but not a ton of revision cases so i have no real brilliant idea of how to perform a better fixation with another pocket or screw. i wish i could give you a better answer but that is an honest one. if i am not your right surgeon, i have no offense. my goal is for you to have the best care you can, and i want to be honest about my experience level with difficult revision cases for chin implants.
best,
sml