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The Wrinkle in Botox

January 10, 2014

The Wrinkle in Botox

Why you can still expect to have a Facelift

Botox Birmingham ALWikipedia’s definition for wrinkle “is a fold, ridge or crease in the skin.”   Botox is a wonderful medical break-through that has altered how some women smile, or lack thereof.  Just like many medical breakthrough products, Botox is often over-sold to the general public giving them an unrealistic expectation of results and, often, misconceptions about turning back the clock or stopping the aging process altogether.  Medical technology has yet to advance enough to alter our DNA and stop the aging process, but has given us products such as Botox that can help prevent wrinkles from occurring to some degree.

Botox is a product that paralyzes the muscles in the injected area.  Since most wrinkles are created from the stress of the underlying muscles, paralyzing those muscles helps to prevent the muscles from contracting thus it prevents skin folds from occurring.  When used prior to the appearance of wrinkles, then Botox is preventing those folds from occurring, thus the signs of aging.  When used after the signs of aging are present, then Botox assists those muscles from contracting thus relaxing the fold, or wrinkle.  Most patients can see visible improvement over time after consistent use.  However, the “wrinkle” in Botox is that is does not erase those deep wrinkles once they are formed, but can help minimize their appearance.

Deep wrinkles are the manifestations of muscle contractions over a period of time.  Wrinkles are more than just folds, they are the visible signs of soft tissue having been broken down from the stress of the muscle contracting.  A tissue replacement, such as artificial fillers or fat grafting, is often recommended to achieve the desired result of minimizing the appearance of wrinkles beyond the capabilities of Botox.

Common areas for Botox Cosmetic are the forehead, glabella (between the eyebrows), and the crow’s feet area around the eyes.  Injecting Botox to frown lines is not advisable unless you wish to paralyze your smile for about 4-6 months.  Even if you could obtain some benefit from Botox injections to the frown lines (laugh lines – or the parentheses lines that extend from our nose down to the corners of our mouth), then the manifestations of aging would still exist as gravity is a proven cosmetic disadvantage to our facial structure.  Botox injections cannot prevent gravity from pulling down the soft tissues of our cheeks contributing to those laugh lines and creating those jowls which in turn help create marionette lines from the corner of the mouth extending down the sides of the chin.

Since it is clear no one would want to Botox those frown lines, the aging process in that area will continue thus leading to a more traditional procedure such as a facelift.  Other factors that can help minimize the appearance of wrinkles are skin care, using sun-block protection, drinking plenty of water to keep the skin hydrated, and maintaining a healthy weight.  Botox is a great product for the prevention of forehead wrinkles, but one should understand it isn’t a magic potion for all areas of the face.

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The Ins and Outs of Rhinoplasty by Dr. Paul Howard

April 24, 2013

By its very nature, Rhinoplasty is one of the most personal of Plastic Surgical procedures.  Many people define the way they look and reflect their ethnicity on their noses and any changes anticipated must be fully discussed pre-operatively.  To do this the patient must have a firm and unwavering commitment to facial change as well as an honest and realistic expectation about the nose they wish to have.  This may start with a look through today’s fashion magazines to see what the “beautiful people” look like.  While it is rarely possible to recreate another’s nose, it does provide a starting point and does give the Plastic Surgeon a general idea of what the patient wants.  The process can then begin to alter the patient’s expectations to something nearer to reality.  Every patient should expect to have a more attractive nose that also breathes well, but not every patient can have the perfect little turned-up nose seen in so many of our current movie actresses.  Once the Plastic Surgeon gets a general idea of what the patient desires, then he/she can begin discussion of the details of the operation and what may or may not be possible.  During this part of the consultation, drawing expected results on the pre-operative photos or utilizing computer imaging is essential.  The only caveat regarding computer imaging is that it is always better if the operating surgeon does the imaging so that the imaged results are as close to realistic as possible.

Explaining the details of the procedure is important as the possibility of complications is hidden in these details.  For instance, describing a dorsal hump reduction should lead to the possibility of a small elevation at the bone-cartilage junction and in large reductions leads to a discussion of osteotomies and supra-tip problems.  We usually perform a septoplasty as straightening the outside of the nose can incur septal deviations that cause breathing difficulties if no septoplasty is performed.  Additionally, the sub-mucous resection of the septal cartilage can be replaced (banked) for possible future use or used to help define a nasal tip or to open an internal valve or straighten the cartilaginous dorsal septum.

The thickness or thinness of the skin needs to be addressed as each can affect the visualized result; thick skin will camouflage tip contouring while thin skin may show the tip architecture created in the finest detail.  Therefore, in a thin skinned patient more discussion of tip detail is crucial.  Explaining planes, cartilage breaks, and light reflexes may then become important.

The most important pre-operative information that must be understood clearly by the patient is that it takes at least 6 months and usually up to a year before the final result is realized and that any necessary revisions should wait at least 6 months in most circumstances.  It is important to not over-sale the cosmetic rhinoplasty.

From the Plastic Surgeon’s point-of-view, reconstructive and even cosmetic rhinoplasty is challenging and has a “steep learning curve” which means it takes a lot of cases to become facile with the instruments and the operation.  I personally was trained by one the best rhinoplasty surgeons ever (see: Rhinoplasty Tetralogy by D. Ralph Millard, Jr., MD).  My early practice encompassed a lot of broken noses due to automobile or physical trauma.  Then I gained a reputation for cleft lip and palate as well as the most difficult rhinoplasties on infants and children.  After 20 years of experience I now only concentrate on teenage and adult cleft lip rhinoplasties, complex rhinoplasty due to trauma and most cosmetic rhinoplasty.   After an extensive 26 year experience, I still find rhinoplasty to be the most taxing and the most rewarding operation that I perform.

Dr. Paul Howard is a Real Board Certified Plastic Surgeon in Birmingham, Alabama.

To Schedule a Consultation call 205-877-PAUL

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The Hidden Risks of Homeopathic and Herbal Supplements on Plastic Surgery by Dr. Paul Howard

March 21, 2013

The use of complimentary or alternative medicines such as those found in herbal or homeopathic preparations has increased from 20% or our patient population to more than 60% of our patients.  The fascination of herbals, teas, and homeopathic products exists because people believe these medicines to be “natural” and therefore perceived to be “safe.”  Only recently have these products been scrutinized carefully by the medical community to determine how safe they actually are.  Safety issues are being addressed due to the fact that there are an increasing number of reports describing bleeding

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Dr Paul Howard Board Certified Plastic Surgeon Birmingham Alabama

complications due to herbal remedies.  We now know the chemistry of most herbals so we can now identify the substances within each herbal preparation that are likely to cause bleeding problems.  To date, the only documented sequelae of herbals that effects Plastic Surgery is the increased risk of peri-operative and post-operative bleeding which usually manifests as more swelling and bruising than one would normally see.  In more severe cases, these homeopathic medications may even cause significant bleeding and hematomas.

A partial list of common herbal supplements that are known to cause bleeding problems is provided:

Chinese Agrimony

Chinese Peony

Feverfew

Fritillaria Bulbs

Dan Shen

Devil’s Claw

Garlic

Geum Japonicum

Ginger

Ginkgo

Ginseng

Licorice

Oil of Wintergreen

Poncitrin

Red Chili Pepper

Saw Palmetto

Other dietary supplements known to effect healing or cause bleeding:

Chondroitin & Glucosamine

Fish Oil

Vitamin E

As a general rule of thumb, any herbal supplement which is known to cause or have any pharmaceutical activity should be discontinued 2 weeks prior to a general anesthetic or outpatient surgery under local or sedation.  Since many herbal or homeopathic formulations contain numerous plant extracts, it is best to stop all homeopathic remedies including herbal teas a full 2 weeks before surgery.  Patients may renew taking their supplements once uncomplicated healing has progressed for at least one week post-operatively.  It is probably in the patient’s best interest to assume all homeopathic supplements have the potential to effect healing and should be discontinued 2 weeks prior to surgery.

Dr. Paul S. Howard, Board Certified Plastic Surgeon Birmingham, Alabama

Preparing for Plastic Surgery by Dr. Paul S. Howard

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On the Training of Horses, Linebackers, Pilots and Plastic Surgeons by Dr. Paul Howard

October 11, 2012

The critical reader may come to the opinion quickly that I am only a Plastic Surgeon and probably know little about training horses or football players.  While this is essentially true, I don’t believe it disqualifies me to comment on other fields of endeavor that require many of the same complex skills that are inherit to the Plastic Surgeon.

The training of surgeons is unlike any other field of endeavor.  One can read massive amounts of material, study diligently for four years of medical school, memorize the indications for an operation, actually study the pertinent anatomy and how to perform an operation and yet know virtually nothing without taking the final exam by incising the patient’s skin and performing an actual procedure where the stakes are as high as they can be.  This discipline is entirely different than any other medical specialty as the requisite study of disease is not the endpoint of training, it is the ante that allows one in the real game which is the application of knowledge to perform a mechanical skill (surgery) which is basically unnatural and requires skills that are not genetic but entirely learned.  Since surgery is learned behavior, there is no way to be graded except by the subjective appraisal of a competent surgeon.  As time evolves and the surgeon becomes independently proficient, the grading of results requires continuous, honest self-assessment of one’s results.  The built-in weakness of the surgical training paradigm is the quality of the “on-the-job” training.  This is the primary reason why surgical, and more specifically, Plastic Surgical training, can lead to widely diffuse results in the quality of the surgeon.  These facts became self-evident to me and led me to seek the most talented and well known surgeons of my era of medicine.  Since we learn surgery by watching and imitating others, it makes perfect sense to seek the best to emulate.  This quest is how I came to know John Kirklin, M.D, Ralph Millard, M.D, and Paul Tessier, M.D.  For those who are unfamiliar with the names, these are the best of the best in surgery.

Let me begin by admitting that I am a hero worshipper.  It happens that I have a small but unique set of personal heroes that I have accumulated over a lifetime.  These men have excelled in their respective fields which happen to include the thoroughbred racing business, the aircraft industry, the National Football League, and the field of Plastic Surgery.

Those who only know horse racing by watching the Kentucky Derby the first Saturday in May every year are not privy to the complexities of thoroughbred breeding, training, and racing.  You may notice the atmosphere in Louisville, KY at Churchill Downs includes beautiful hats and the unfettered consumption of Kentucky bourbon in the form of the ever present Mint Julep.  This pageantry belies the complexity of horse genetics and gene pools as well as the training of these extremely fragile animals.  Additionally, they are trained to race beginning as a two year old animal.  The three year olds that race the Derby are still adolescent animals and behave in many ways the same as our teenaged children.  Yet, the results of their early races can lead to a multi-million dollar horse, both as a racer and later as an addition to the thoroughbred gene pool.

Dr. Ruel Cowles is a veterinary physician/surgeon whose practice and life is dedicated to the healthcare of these majestic animals.  One of my mentors, John Kirklin, MD, was an established horseman and was convinced that race horses were essentially untrained whereas gaited, dressage, and jumpers were the only horses truly trained.  Dr. Kirklin also opined that a good jumper must be at least 10 years of age.  Racing 3 year-olds in packs of 10-20 over a mile long course against the best 3 year-olds in the world would probably be a daunting task for a 10 year-old thoroughbred.   It’s like training a 15 year-old to pitch in the major leagues – you can never be sure exactly what you will get.

Dr. Cowles embodies the best of clinical veterinary medicine as well as the intellect to excel as a horse breeder.  Dr. Ruel Cowles is one of my heroes.

I have more than a passing interest in the sport of American Football.  I was, as many of my colleagues were, a high school football player.  I managed to keep my NFL dreams alive through my first year of college where the physical and mental rigors of the game caused me to turn in my shoulder pads to pursue academics full-time.  As such I developed an almost unhealthy respect for those players who made it to the NFL.  I particularly liked linebackers as that was my chosen position.  The day I met Kevin Greene, at the time playing for the LA Rams, I realized who I would have become if I had the fortitude to continue playing.  Kevin was a walk-on at Auburn University in the early 1980’s under Coach Pat Dye.  He showed early on his pass rushing prowess, but only a few NFL scouts agreed and was chosen by LA in the sixth round of the draft. From his first training camp, Kevin’s coaches and teammates understood that going easy on the veterans was not part of his game.  All Pro offensive tackle Jackie Slater found out Kevin was a “maniac” on every play, pre-season or not.  Kevin was soon inserted in the line-up for the Rams and there he stayed.  After leaving the Rams for Pittsburgh, he truly found his identity, grew his hair to his shoulders, married a beautiful Alabama girl, and became a favorite in Pittsburgh because of his aggressive and relentless style of play.  He was known for sacking the quarterback but in fact was a complete linebacker in the 3-4 scheme.  I cannot remember a single time that a running-back or receiver managed to even fall forward after he got his hands on them.  I was privileged to be Kevin’s friend through the entirety of his 16 year NFL career including multiple Pro Bowls and defensive linebacker awards.  His intensity and dedication to his craft were unparalleled.   Ten years after his retirement from the NFL, he still holds the career sack total among linebackers.  Today, Kevin is imparting his knowledge to younger players as the outside linebacker coach for the Green Bay Packers.  Kevin is also one of my heroes.

I’ve known but a few fighter pilots and one submariner personally.  There are a few common traits these people have that separate them from the rest of us.  First, they all have very acute and agile minds that can assimilate knowledge quickly and apply it so that they are constantly evaluating their performance and improving by self-evaluating and reflection.  These traits are similar to those needed for Plastic Surgeons with the added immediacy of going Mach II or being thousands of feet under water.

As a first-year resident under Dr. Ralph Millard, I became acquainted with Dr. Gregory Lovaas senior resident under Millard.  Greg was like a xenon light in a room full of candles.  He shown brightly and was a wonderful teacher to me.  Knowing Greg as I did it was not easy to imagine the government putting him in a single seat F-104 fighter with nuclear weapons.  As I learned more about Greg, I realized he was the perfect personality for such a dangerous, in-your-face profession.  Greg, as most intelligent people do, had a wondrous sense of humor that may or may not have served him well over the years. My most vivid memory of Greg is the fighter pilot/Plastic Surgeon maniac.  He taught me the fighter pilot credo – “sometimes wrong, never in doubt.”  Greg Lovaas is one of my heroes.

A young boy and his twin brother grew up fatherless during the Great Depression in rural Griffin, Georgia.  Times were tough for everyone and the twins did the best they could for themselves and their family.  As they became teenagers, sports helped fill their days.  It was an accident playing baseball that knocked out the two front teeth on one of the boys causing a speech impediment and a lasting impression as he did not have enough money to receive the necessary dental care.  The twins with no prospects on the horizon lied about their age and enlisted in the Army and the Navy.  The story goes that the twins couldn’t understand why the new recruits were homesick and even cried at night while the twins were elevated from their Hell to three square meals a day and they weren’t worked very hard.  The addition of free dental care made WWII a life altering experience, all for the good.

New pair of shoes, one suit, two new teeth and training in electronics were enough to start a new life several years after the war with a new wife and further training in repair of the new-fangled American commodity – the television set.  The younger of the twins was desperately trying to live the American Dream.  Fixing the notoriously unreliable TVs and their vacuum tubes was a decent job.  Utilizing his military training and hands-on electronics experience, twin got a job with Lockheed Aircraft in Marietta, Georgia where he taught electronics to the new hires needed to build the C-130 “Hercules” and the new super airliner – the L-1011.  The younger twin learned he had a knack for teaching and especially training people to do a job.  He eventually parlayed this experience into industrial training programs for four Southern states eventually having a training facility posthumously named after him in Montgomery, Alabama.  Twin number two, and one of my heroes, was George L. Howard, my father.

The training of Plastic Surgeon is a long grueling process due to massive amounts of material to learn, but more importantly the aptitude, mental acuity, and complex decision making necessary.  Most students of Plastic Surgery realize that the training is so long (± 6 years) because the depth of knowledge necessary is vast and by necessity practicing Plastic Surgery requires a malleable mind to attack each challenge with freshness, intensity, and thoughtfulness. These attributes are not something one can read about, but can only be obtained by acquiring the knowledge from others who already have it.  This is why it is so important to ask the credentials of a Plastic Surgeon so one can surmise the quality of his/her education in Plastic Surgery.  In Plastic Surgery, it makes perfect sense that truly the best Plastic Surgeons are the best teachers.  My final heroes are two of my Plastic Surgery mentors that encompass the best that our field has ever created.  D. Ralph Millard, Jr., M.D., and Paul Tessier, M.D. are also my heroes.

Recent history has taught us the penalty to be paid by the consumer of Plastic Surgery who is swayed by the exquisite marketing of doctors who believe for financial reasons that the least amount of education in the intricacies of Plastic Surgery is somehow better than the full training program that has been in place for 30 years.  There is no other example of attenuated training in any of the surgical specialties.  Neurosurgeons are required to train in all aspects of neurosurgery and even take a year of basic neurology training even though few neurosurgeons practice all of the aspects of the specialty.  This is mainly because for the last 100 years it is clearly shown that almost all specialists benefit from a wide and diverse basis of knowledge leading to calmness under pressure and the ability to elicit a laser-focus required of the expert.  This is true for training many kinds of endeavors and one will never find a short-cut to the training of the best race horses, NFL linebackers nor in the making of aircraft or the training of Plastic Surgeons.  Hippocrates said it best in his aphorism “Life is short, and the art is long; opportunityfleeting; experience perilous, and decision difficult.”  The first time I heard this warning was from the great cardiac surgeon John Kirklin, M.D. in his famous surgical “bluebook” to help train young cardiovascular surgeons.

To learn more about Dr. Paul Howard, please visit his web sites:

www.paulhowardmd.com

www.TheHowardlift.com

www.SexyFullerLips.com

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Gynecomastia by Dr. Paul Howard

June 11, 2012

Gynecomastia is a deformity that usually manifests in teenage boys where there is massive hormone stimulation of the nascent breast tissue causing enlargement associated with pain and a very disturbing physical deformity.  Gynecomastia tends to run in families therefor there is some genetic component and usually becomes manifest in the early teenage years when male hormones are active.  It is usually associated with mild to moderate torso obesity.  The deformity is worsened by weight as there usually an aspect of the deformity that is fat tissue in addition to tender breast tissue.  It is that fat portion of the deformity that has caused insurance carriers to demand weight loss as well as hormonal studies to document and treat the disease.  There are insurance carriers who specify in their contracts that they explicitly do not cover gynecomastia resection under any circumstance.

The treatment of gynecomastia in adolescents should include, if necessary, an attempt at weight loss followed by surgical resection, usually tumescent liposuction technology.  Unfortunately, if surgery is performed in the early to mid-teenage years there is a possibility of recurrence, usually beneath the nipple/areolar complex, as it is virtually impossible to remove the breast tissue in its entirely.  Additionally, any upper fluctuation in weight will also give the appearance of a recurrence.

Gynecomastia in adult males is usually due to excessive marijuana smoking and/or abuse of anabolic steroids or large doses of testosterone.  Most men who fit this profile are body builders with a reasonable low body fat. Those with higher body fat percentages also have a fatty component to the deformity.  Most body builders who “stack” their anabolics also take an anti-estrogen drug trying to prevent the painful breast enlargement.  Surgical removal for pain relief and cosmetic chest improvement usually requires direct excision.  These men usually have hypertrophic and highly vascular chests causing common hematoma formation post-operatively.  Again, recurrence can be common if the patient continues to use steroids.

Gynecomastia, especially the teenage version, occurs at a very unsettled age when there may be extreme body dysmorphism.  Children this age can be unpleasantly negative at a time when undressing for the gym or going to the swimming pool can be a traumatic event.  These psychological issues are reason enough to operate early even if a re-do becomes necessary.

Call today to schedule your consultation with Dr. Howard 205-877-PAUL

Dr. Paul Howard on Google+

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Fibroblasts vs. Stem Cells by Dr. Paul Howard

May 31, 2012

The TV news media is reporting the latest “break-through” in cosmetic medicine science.  Evidently for a mere $4,000 one can take a punch biopsy of a patient’s skin, send it to a lab where fibroblasts are isolated, cultured and expanded.  This results in millions of fibroblasts which are then re-injected into the face to rejuvenate the tissues as fibroblasts are known to synthesize the protein collagen which is lost in the aging face.  This clearly is a break-through in cell biology albeit an expensive one and not a popular alternative since it doesn’t last longer than 6 months.

A different technology has been available for several years and achieves pretty much the same thing at a fraction of the cost, and it lasts forever.  Adipose derived stem cells are isolated from liposuction aspirate and then re-introduced into the areas requiring rejuvenation.  The stem cells are more basic precursor cells to fibroblasts thus are thought to transform into fibroblasts as well as other cell types that increase vascularity and provide many of the trophic growth factors that help rejuvenate skin.  Depending on their environment, stem cells can be encouraged to form cartilage, even re-create osteoblasts that form bones.  Therefore, stem cells have been used for a wide variety of clinical problems including skin rejuvenation, joint cartilage re-growth and healing, wound healing and even re-growth of cardiac muscle tissue.

All of these new technologies whether or not they are “FDA approved” need to be evaluated through the prism of overall scientific advances.  It seems that the imprimatur of the FDA allows the science to be exploited for marketing gain by the few.  Regardless, FDA involvement with these new scientific advances has not been well defined and tends to allow for marketing adulteration of the product  in question often misleading the consumer regarding other available options

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Chin Augmentation

May 31, 2012

In Hollywood, where most of the talent trades on their facial attractiveness, it has been common for both men and women to enhance their profiles with chin enhancement.  Especially in men a strong jawline and profile are a must for matinee idol handsomeness.   In an industry where attractiveness is the primary currency, chin surgery has always been common; more common than anybody suspected.  So it is not a surprise that the American Society of Plastic Surgeons statistics show that chin augmentation with chin implants has risen 71% making it the fastest growing plastic surgical procedure.  Slightly more men than women are undergoing the procedure which is not a surprise due to the large cachet placed on a strong chin and jawline in men.

Implants for chin augmentation have been around for 30 years or more so the science behind the procedure is fairly well worked out.  Commonly, an incision is placed in the mouth below the front teeth on the bottom (a skin incision below the chin is also feasible).  A pocket is then created over the boney part of the chin or mentum.  This pocket is carefully placed below the tooth roots and away from the nerves that supply sensation to the lower lip.  Small improvements of 4-5 mm are easily achieved with a variety of silastic (silicone) implants with various shapes and sizes.  Most experienced surgeons would agree that a chin augmentation of 10mm or more is more difficult to obtain with an implant.  These large augmentations are associated with a small chin (microgenia) as well as a poorly defined, obtuse, neck contour.  Simply placing an implant gives minimal improvement to the neck.  Large implants are more likely to cause boney erosion of the chin due to their size and the tension required to advance the tight soft tissues.  For this reason, large chin advancements of a centimeter or more are frequently achieved with a different operation known as a genioplasty.  A genioplasty is performed again through an oral incision, but rather than placing a silastic implant, the chin bone is cut in a horizontal direction below the tooth roots so that the small chin may be advanced and fixed in position with titanium plates and screws.  If the small amount of titanium hardware becomes a problem it may be removed after healing of the bone at about 6 months post-operatively.  The intrinsic beauty of the genioplasty is that the neck muscles are left attached to the boney chin and as the chin is moved forward to effect the augmentation, the neck muscles are also tightened improving the once obtuse neck line.  In the rare instance of a chin implant infection, removing the implant and performing a genioplasty can salvage the result as the small amount of titanium used for fixation almost never causes an infection.

The most common complications of chin implant surgery are the rare infection, rare boney erosion involving tooth roots, and more commonly prolonged lip numbness (rarely permanent) with the most frequent complication being inadequate chin projection as well as over-projection of the chin giving a profile in women that it too strong and sometimes masculine.  Occasionally, a chin implant that is not properly healed can shift causing the chin to be asymmetric.  Even years after fully healing, a trauma to the chin implant can cause a secondary hematoma and inflammation necessitating implant removal.  On a very rare occasion a lower jaw (mandibular) tooth abscess can secondarily infect a chin implant, but not a genioplasty.

Over the years, many creative surgeons have tried to create chin implants with mesh material such as mersilene or prolene mesh.  The primary problem with porous materials is that they can get chronically infected causing prolonged oral drainage.  Also, these porous implants become incorporated into the chin soft tissues and thus are impossible to revise (bigger or smaller) and can be very difficult to remove.  The good news is that these so called “chin cripples” can be salvaged by a well performed genioplasty.

Chin augmentation is one of those procedures that lends itself to facial imaging.  Using the already well known proportions, the exact profile can be agreed upon pre-operatively so that no misunderstandings develop post-operatively.

All in all, chin augmentation is one of the easiest and most satisfying operations performed by Plastic Surgeons.  Naturally, when studying the profile, the nasal profile comes under scrutiny and in many cases rhinoplasty and chin augmentation are done simultaneously to overhaul the entire profile all at once.  Again, facial imaging can predict the profile that is desired.  One warning is in order:  Many times dental malformations (malocclusions) can mask themselves as a weak profile.  A good dental evaluation to rule out malocclusions and dental caries, especially in the lower jar, is indicated pre-operatively.  Beware the dentist/orthodontist with today’s fancy facial imaging software.  Not everyone with minor malocclusions needs $5,000 of orthodontics on a fully formed jaw.  These orthodontists many times feel the need to recommend both nasal and chin surgery acting like they and their referrals are a necessity.  This is the tail wagging the dog.  It should be very easy to identify fully trained Plastic Surgeons to perform both chin augmentation as well as the rhinoplasty in a single operation.

Call today for your consultation 205-871-3361

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