Plastic Surgery Unplugged
with Dr. Raghu Athré: Episode 2
Welcome back to “Plastic Surgery Unplugged with Dr. Raghu Athré!” Our new podcast aims to share behind-the-scenes knowledge of the plastic surgery industry with premium interviews, hot topic deep-dives, and others tips and tricks to help you feel confident and beautiful with the help of Athré Facial Plastics.
Listen on YouTube, Apple Podcasts, Spotify, Podbean, or Google Podcasts—and don’t forget to check out our first incredible interview with Dr. William Silver on episode 1.
Don’t forget to subscribe and share with friends and family. Here’s episode 2: Talking About Chin Augmentation with Dr. William Silver.” Thanks for listening!
[Audio transcription via Rev.com:]
“Talking About Chin Augmentation with Dr. William Silver”
Audio clip:
Hello, everyone. You are listening to “Plastic Surgery Unplugged with Dr. Raghu Athre.”
Dr. Raghu Athre:
[inaudible 00:00:11] So after our first initial podcast, I guess it was a success and we’ve been asked to do multiple of these. So today I’m joined again on our podcast with Dr. William Silver, and we are linking between Houston and Atlanta, Georgia.
And let’s see, today we’re going to talk about chin augmentation. I think that’s the primer that I had given you and let me go ahead and share my screen. All right, so these are the pictures that I had sent you. She’s a nice little young girl that had come into my office with her mother. She is a college student, about to enter into her freshman year and her story is as such. She hates her nose, so I always start off a consultation with, if you had a magic wand, what would you do?
Dr. Raghu Athre:
And so she says, “I’d change my nose, I’ve been thinking about this for years. Ever since I was about 13 years old, my nose kind of took on the shape and it’s been a cause of insecurity.” She’s been teased about it and so mom finally acquiesced to bringing her into the office and said, she’s a pretty quiet girl, keeps to herself. She’s been bugging her mom about her nose and that’s the information we have so far.
Healthy, no prior surgeries, no drug allergies, no medications. When I asked her about the magic wand, what she wants, she says, “I hate the bump.” She says, “I want a smaller nose, my nose looks too big on my face.” There we go.
Dr. William Silver:
Well, anyway, it’s good to talk with you again this morning, Raghu.
Dr. Raghu Athre:
Same here.
Dr. William Silver:
I think you brought up the most important part and that is when a patient comes into your office, the most important thing you want to do, is to listen. And comes the question that as she described everything about what she wanted to see changed or done, to make her feel better about herself. You listened and in your own mind, you do the analysis and you verify with the patient.
Then comes the question, is we look at this particular picture. You notice that there is a little bit of loss of chin projection. Now the patient, according to what you’ve just told me, did not mention this. So it comes up to question, how do you as a facial plastic rhinoplasty surgeon, address the issue if you feel that after you’ve performed this particular change on this young lady and her chin is still somewhat small or retracted.
How do you bring that issue up to a patient, without number one, offending the patient, or more importantly, to educate the patient as to how a change with her chin, will accentuate the good changes to her nose.
Dr. William Silver:
And I say this in the sense that not every patient is going to accept what you say right off the bat. So the object is to be able to share with them, how the chin and the nose compliment the entire face.
If the chin is actually brought forward, it will decrease the actual projection appearance of the nose. So it’s up to the operating surgeon to be able to bring this forward in a manner that will educate the patient, to have them understand what this possible additional procedure would do to help with their total appearance.
Dr. Raghu Athre:
So what I like, I’m going to tell you what I do, and you can kind of throw in your two cents. So when I’m examining the patient, I actually tell the patient what I’m examining. So I tell them that even though they’re here for a rhinoplasty, that’s actually the last thing that I look at. Because you can get so fixated into just looking at the nose that you miss the bigger picture.
So I tell them the first thing I look at is what I call the general portion of the exam, male or female, ethnicity, or even a parent ethnicity, skin thickness. Are they tall? Are they short? General body habitus? So just kind of the overall, what do they look like? I tell them if I was walking in a mall and I saw them at a distance of 10 feet, what’s my first snap judgment impression?
Dr. Raghu Athre:
And then the second thing I say is that before I jumped to the nose, I start looking at the face and looking at craniofacial development. And so what I tell them is I look at this point right here, this point right here, and this point right here and on profile, those points should make a plane, which is perpendicular to the floor. And this girl, she has this kind of negative vector right here. Now, some people will agree with me at this point, which is great and some people are still looking at me like I’m from Mars.
So once I’ve gotten past that in the nasal examination, I find this is actually the best utilization of photographic imaging and our imaging software. Because I’ll show them what they look like with just a chin implant, with nothing else and automatically it makes that nose look smaller and then they go, “Okay, I see what you’re saying.” Your thoughts?
Dr. William Silver:
[inaudible 00:06:55] I think that you do bring up an additional factor here when the patient has not mentioned the chin. In other words, you may have another situation with the same patient that would come in and they themselves have addressed it. So there’s a different approach from one that has not mentioned it to one that has mentioned it, in conjunction with their nose, either because they have seen their own facial profile or others have talked to them about it, as opposed to one that now you’re educating.
Dr. William Silver:
And I agree, I think that the pictures particularly now that we have computer imaging, is such a dramatic expression or tool to be able to share with the patient what they can look like. So the patients themselves have an opportunity to evaluate it and very often, as you mentioned, they’ll come in with someone else and it’s good to have this.
And I use the computer, not as a guarantee to the patient. This is what you’re going to look like, but I use it strictly as a communication tool. And that is how you go about doing the evaluation.
[crosstalk 00:08:17] Now, part of the education, I do have some drawings that I’ll often show them that show how the effects of HGN, projection of the chin has on the total appearance of the nose. And I found that is very helpful, to educate the patients as to accepting that additional procedure.
Dr. Raghu Athre:
So in your practice, are you using 2D imaging or 3D imaging?
Dr. William Silver:
I use primarily two dimensional imaging-
Dr. William Silver:
I find that when I tried to use the 3D dimensional images, this is just from my experience, that it comes out somewhat stark as you rotate it around. And it’s easier for me in two dimensional imaging. It’s easier for me to focus specifically on the areas that I want to focus on. Although I have access to 3D computer imaging, but in my experience, I find that it’s a little bit of overplay from that point of view. Excuse me.
Dr. Raghu Athre:
Yes. No, no worries. No, I agree. I think that there’s been a big push nowadays with these 3D imaging. A lot of software packages are coming out with 3D imaging and one of the things that I’ve noticed is you lose a lot of detail. For example, on this 2D picture, you can see the sharpness of where her chin is and you really kind of lose some of those fine details on the 3D imaging.
I’m going to close this window and I’m going to bring something else up in just a second. So let me see if I can pull that.
Dr. William Silver:
Also, what I will do as you’re pulling this up. I will take patients who have had previous chin implants to be able to show them. Obviously I’ll use these patients images that have given me permission to use, and I will show them the before and after pictures to give them an idea of how other patients have experienced this additional procedure of a chin implant.
Dr. Raghu Athre:
So fast forwarding. So this is her on two months post-op and we actually did do a chin implant in her. There was a lot of him hauling back and forth, and it mainly was a financial thing that was causing the reluctance. But then with the imaging, I think the imaging was a great tool to show mom exactly what her daughter would look like with the chin implants.
This is a size small extended anatomic silastic chin implant. And we of course, did just a conservative rhinoplasty, just make her a lot more feminine and in balance. So one of the things that I really love is, I really love the chin where it adds that one third to the face. And I think it just adds that sense of balance and proportion that was missing in this photograph right here.
Dr. William Silver:
You bring up two more important points. As you look at this particular picture, if you will look at a vector, if you do it just from the point of the chin out towards the nose and from a far before you did the chin insertion, then you would see that the emphasis is to make the nose look more prominent. As you reduce the effect of the chin negative vector.
After the chin implant, you see that it literally makes the nose now more proportionate to a relatively small phase. The second point that you brought up was a matter of costs. I think different surgeons, including yourself, and maybe others that may be watching, may charge different amounts if you’re doing a chin augmentation, a chin implant with a rhinoplasty. And I have found over the years that about maybe as high as maybe one out of every 10 or maybe one out of every five or eight patients may need a chin plant, just on the borderline.
Dr. William Silver:
And I do say that if money is a factor and I feel it would make that much difference, I want to make sure that the patient gets the best result. And very often I have only charged them for the actual implant. And I don’t say this to give something away or to take away from it, but I find that sometimes it removes the idea that a surgeon is trying to sell a procedure.
And I have found that in some of those cases, it has paid off in immense amounts of appreciation to the patient who in turn shares that appreciation with others. And so, as a result, it’s not a question of a loss of money, but it’s an idea that now you have created, what in your own mind you want to have the best for that patient.
Dr. Raghu Athre:
You want the best outcome, you want the best absolute result.
Dr. William Silver:
Right.
Dr. Raghu Athre:
Yeah. All right, so I’m going to pull, give me a second. I’m going to pull up cause you had a nice list of questions and I brought some of these topics up in terms of choice of implant and such. So I’m going to pull up your presentation that you sent me, and then… Let’s see how to do that.
Dr. William Silver:
By the way, while you’re working on that, I’ll share with you. Often the patients want to know how much more does it add to the recovery, which I think is an important thing to emphasize to the patient. A rhinoplasty for the most part is usually not a painful procedure. It’s sometimes uncomfortable because they have to breathe through their mouth and the nose will be stuffed up. But I tell them there is very little additional recovery time for a chin implant.
Dr. Raghu Athre:
What I find in general is with the rhinoplasty. I tell my patients roughly five to six days and they feel as if they have the worst sinus infection of their life. That’s something somebody can relate to. They feel like their head feels heavy, they can’t breathe through their nose. They’re breathing through their mouth, very dry mouth, cottonmouth, lack of taste, that’s primarily what they feel.
Once the packing comes out, which is about five to six days for me, I know everybody has their own formula for that. They feel a lot better. What I find with the chin implant is…the good news about doing a chin implant with the rhinoplasty is it makes them forget completely about the rhinoplasty. So most of the patients who’ve had a chin implant say it’s not pain as much as it is soreness. One of my patients said it best, it feels like you’re going to get your braces tightened.
Dr. Raghu Athre:
And so you feel a lot of soreness. It’s hard to open your mouth all the way, chewing, biting for about five to seven days is a little tender. And I think that was very good… And I use these kinds of analogies so that other people can kind of relate to, it gives you something you can put your finger on. So you were talking earlier about the facial plane and I also talked about the facial plane. So here is for everybody watching our podcast kind of a pictorial representation and Dr. Silver has been pretty nice enough to put this presentation together.
Dr. Raghu Athre:
So you can really see, I showed you one specific case point, but you can see multiple case presentations here of how you can see where it really adds that balance to the lower one-third of the face. And one of the additional things that I really love about these patients when you do this.
And I think a lot of women really like this, is it lengthens the neck. So it gives them that long feminine neck as well, which is kind of missing. You can see it very clearly here, it’s kind of missing here due to the fact that you have the negative vector on the chin. I prefer silastic implants. How about you, Dr. Silver?
Dr. William Silver:
Yeah, for the most part, I would say 99% I’ll use the extended silastic chin implants. And I think that they have offered the ease of insertion and another point that I do say, that I do tell the patients, if they are a little concerned about having a chin implant. Is one of the most important things is if the worst thing would happen and maybe this has happened in maybe less than 1% of the patients, if they didn’t like it, it’s very easy to remove it on a little tiny procedure in the office.
Dr. Raghu Athre:
It takes less than five minutes and I tell them that, when there is that little bit of that reluctance on the patient, just from hearing the word implant, what they feel. I tell them if you hate it, give me six weeks. If you hate it, I’ll take it out for free because it really is something that is so easy to remove in the office.
Dr. William Silver:
Let’s leave this picture that’s on here now and let me [inaudible 00:19:03] little talk about it. If you’ll notice on the picture here, the question that I asked, which nose projects the most? And if you look at it, you will see that the picture on the right looks like it sticks out the farthest.
Dr. Raghu Athre:
Right.
Dr. William Silver:
More than the one on the left. And yet, if you look at it carefully, the nose is the same. The major difference in each of these pictures is the slope of the forest or the retraction of the chin. So I just wanted to make sure that for some of the people who are watching the podcast to realize how the chin does affect the appearance of the nose. And if you could go back up to the top image, I just wanted to mention something else. This is a method that you and I have worked on when we work together.
Dr. William Silver:
This is a method that very often is used to estimate the artistic chin augment or the chin projection. And if you’ll see it’s a line that’s drawn down from, we call the crease of the top of the nose through the edge of the nostril. And if you do that perpendicular to a line that goes from the ear canal to the lower out eye level, that’ll show about where that chin projection artistically should be. And I use this and I’m sure that you use this or a similar method the same way. And I just feel that it’s a way of teaching my eye to look at the patient and also to give the patient an understanding why I might suggest something like that. If they didn’t see it already.
Dr. Raghu Athre:
What I actually do on the photograph for the patient. So all my patients will ask me the same question. I take a photograph with a penny taped to their cheek and they go, what’s the penny for? So, and what I use it for is exactly this, I’ll draw this and when I know that I need a chin and use the penny in order to size exactly to scale the picture to one to one. So I know exactly how many millimeters of augmentation I need.
Dr. William Silver:
Oh great, great.
Dr. Raghu Athre:
So in case someone is using a different lens or anything like that. I know the diameter of a penny, so I can always size that photograph directly to one-to-one size to get the exact size that that would be needed. So I’m going to scroll through a few of these pictures here. Again, I think showing the viewer how important a chin really is to adding to the proportion of not only the face, but really impacting the overall result of a rhinoplasty.
I think this is a great example of what in a male patient, what that chin augmentation really does to add to the rhinoplasty. And here’s another patient. I think this is a nice example, again, of that adding the chin, which helps with the neck as well. So I really like it.
So we’ve got about two minutes left to keep this short and simple. So we don’t get dinged for being too long. Any other caveats we’d like to include on this, Dr. Silver, anything that you can think of that you’d really like?
Dr. William Silver:
I think the most important thing that I want to bring out is that discussions like we’re having between the two of us in different cities and evaluating our experiences is a great opportunity to let individuals know without the formality of having to go to a major lecture. And these are real live patients and I really thank you for sharing this opportunity with you.
Dr. Raghu Athre:
Well, thank you. I think it’s a lot of fun and I’m sure that we’re probably having a full… it’s hard to put on this type of a talk for a full range of viewers. Because we’re probably going to have some viewers who have no medical experience just wanting to learn about it and then some who may be plastic surgeons, this is pretty elementary for me. So it’s kind of hard to put it on, but hopefully it just gives a little bit of a primer.
As I’ve been thinking about this, some of the upcoming talks that I’d really like to do is, I’d like to even see if we can get a live patient to join us. Preferably not in Houston or Atlanta who may want a recommendation, maybe he or she has gone to a surgeon and wants, kind of a blinded recommendation. I think it’d be kind of interesting to say, “Hey, let’s throw some pictures up and see what we come up with.”
Dr. William Silver:
You’re always full of great ideas and I’m thrilled that I have the opportunity of staying close with you.
Dr. Raghu Athre:
Well, it’s been fun. So I will do the same next time, so I think we’ll bid our viewers due this time and I’ll try and pull up another interesting case, something that’s interesting in rhinoplasty, maybe an ethnic nose or different ethnicity, something to give us something to talk about and throw you some pictures and then we’ll see where that goes.
Dr. William Silver:
Have a good day.
Dr. Raghu Athre:
You too.
