Reversal V-Line Jaw Surgery

Q: Dr. Eppley,I’m a 26 yearr old woman from South Korea. I want to do custom facial implants for two sides of my kaw. I had a bad surgery two years ago and they cut off my two sides of jaws way too much and also sliding my chin upward which made my face look unproportional. I want to augment my jaws line. Any suggestions? 

Here’s my history of surgery… I had lower jaws surgery by Maxillofacial doctor in 2005 as I had protruded lower jaws. The doctor moved back my lower jaw about 5-6 mm so the result was very subtle. In 2013 I had two sides of my jaws cut off and my chin sliding in front. (V-line jaw surgery) My face looks unproportion. I have protruded chin than before my first
surgery and I don’t have jaws angle!

Now my desire is to have a proportion face and less protruded chin.

A: Thank you for sending all of your x-rays. You had the classic V-line jaw surgery where the jaw angles are removed and the chin is narrowed and advanced forward. To totally or partial reverse your prior surgery, you would need vertical lengthening jaw angle implants and a setback bony genioplasty. This is the classic ‘reversal V-line jaw surgery’ that I have done any times for those patients who find that their new face is now disproportionate.

Dr. Barry Eppley
Indianapolis, Indiana

Custom Skull Implants

Q: Dr. Eppley, I wanted to ask a very brief question for your blog that is relevant to me, and I believe will help others.

Custom skull implants can cover the entire bony skull, forehead and brow, the scalp tissue permitting. Because of financial constraints I cannot afford multiple implants. However I want augmentation of the temporal area. With a two stage tissue expander is it possible to include the temporal region in this singular total skull implant? Also how far down the lateral orbital rim may the implant extend. I’m aware that the top part is contiguous with the brow and can usually be augmented at the same time. How much exactly of the lateral orbital rim could be covered with this custom skull implant (can it stretch down slightly below the lateral canthus)?

Thank you.

A: Thank you for your inquiry. As best as I can understand your question about custom skull implant coverage, it can be designed to any size or cover any area including that of the temporal region. There may be issues of implant placement, incision size etc that may affect that consideration, but it is not a design restriction. I have done large custom skull implants before.

Dr. Barry Eppley
Indianapolis, Indiana 

Parasagittal Skull Implants

Q: Dr. Eppley, we’ve been emailing for the last 3 years about my skull shape and various skull reshaping methods to improve it. I hope you’re doing well. Last we emailed, I was thinking about getting two parasagittal skull implants which would require a pair of of 2.5 cm incisions.

Is that still the best option today? I was wondering about a single central incision as I think that will be hidden a little better with my naturally thin hair. Do you have an idea of 1) whether that’s possible with 2 implants, and 2) roughly how short we could keep the incision? I recently saw a blog post of yours where you performed a sagittal reduction through a small central incision. This might be a good chance to do a little bit of reduction along with implants.

Finally, are there any long-term health risks with these implants?

A: The truly best option for your skull is to have a combination of a sagittal ridge reduction with custom parasagittal skull implants placed through a 4 to 5 cm incision. It really comes down to whether the sagittal ridge is addressed or not. If it isn’t then the two bilateral smaller incisions would be best. Because the one central incision is essentially going to be he addictive width of the paired incisional approach.

There are no long-term medical risks with these skull implants.

Dr. Barry Eppley
Indianapolis, Indiana

Jaw Implant Bone Erosion

Q: Dr. Eppley, I have read from a few plastic surgeons that bone erosion can occur some time after a jaw/chin implant procedure. (jaw implant bone erosion) Would you mind elaborating on this for me? Will this effect the result in the future? How can I minimize bone erosion?

A: To put those comments into perspective the statement that jaw implant bone erosion occurs implies an active inflammatory bone destructive process…which does not occur. All facial implants, like all body implants including breast implants, create the biologic reaction of tissue adaptation around the implant. This is a normal process that the misinformed interpret erroneously as ‘bone erosion’. It is better turned ‘passive settling’ which means the implant is associated with a pattern or imprint on the bone which is the body’s way of relieving the pressure from an object that is naturally not meant to be there. This may be a millimeter or two of the implant settling into the bone. There may even be bone growth around the edges of the implant up onto the implant.This is a self-limited process and is most commonly associated with smaller facial implants, most commonly standard chin implants. This is not a biologic process that I have seen in much larger implants like wrap around jawline implants or skull implants…probably because the larger size of the implant distributes the pressure of tissue displacement over a broader surface area

Dr. Barry Eppley
Indianapolis, Indiana

Chin Augmentation

Q: Dr. Eppley, I am interested in chin augmentation. I have attached a few photos band a facial analysis report from another surgeon. My goal is to define my jaw, neck, and balance my chin for a chiseled appearance. I am also interested in eradicating the horizontal neck lines. I plan on losing 20lbs before booking a online consultation, but would love to hear your opinion.Thank you.

A:Thank you for sending your pictures. Your chin deficiency is completely of a vertical dimension, you have adequate horizontal projection. Your lower facial third is vertically short. Thus what you need is a vertical lengthening bony genioplasty combined with a submentoplasty neck procedure. Essentially drop the chin and bring up the neck angle. That is what your ‘chin augmentation should consist of and it has nothing to do with a chin implant unless you want to custom design a vertical lengthening chin implant but I advise against since it may not carry the soft tissue chin pad down with it whereas moving the chin bone down will. How much you would like to vertically lengthen your chin is a matter of aesthetic taste and the attached imaging is just one version of it.

Your facial analysis report is non-sensical to me as bimaxillary osteotomies are not an appropriate solution for your facial concerns nor do they address the neck component.

No surgical procedure exists that can improve horizontal neck lines, that is not an achievable goal.

Dr. Barry Eppley
Indianapolis, Indiana

Hip Implants

Q: Dr. Eppley, I am interested in several face and body procedures. For the face I am interested in buccal fat removal and maybe chin augmentation. I really want a more defined Jaw so we would have to talk and see how you could achieve those results. For the body, I am interested in body shape adjustments through liposuction, anatomic waist reduction and maybe fat grafting or hip implants. I have already had liposuction of my waistline done with buttock augmentation with implants but not getting the desired body shape yet.

A: Thank you for sending all of your pictures and detailing your goals. In reviewing the face and the body pictures I can make the following comments:

1) Having been through liposuction and getting buttock implants, your options for further body contouring are now more limited. Not knowing how your liposuction was done, perhaps there may be room for further improvement in waistline reduction but it would not be dramatic. Even with further liposuction the amount of fat you have to harvest would be less than the first time so its use for far grafting would not be substantial. It could be used to add around your buttock implants which appear to be the subfascial location. At best this would add some filling around the buttock implants. Any fat harvested should be used for the buttock region and not wasted on the hips..

2) For larger hips your only option are hip implants. You don’t have enough fat to harvest to provide any hip augmentation effect. Whether the small incision to place them is worthy of the augmentation effect is to be determined.

3) Even with some further waistline reduction and hip augmentation, I don’t see you getting that close to your projected image goals. It would be better than where you are now but those pictures are not that realistic of a goal with your body type.

4) You face would benefit from some thinning/defatting including buccal lipectomies, perioral liposuction, and submental/jawline liposuction. 

5) To achieve a better defined jawline with the facial thinning, the chin is going to have to come out further to help lengthen the jawline. Whether that is done with an implant or a sliding genioplasty can be debated

Dr. Barry Eppley
Indianapolis, Indiana

Jawline Shapes

Q: Dr. Eppley, Could possibly send me two pictures of the difference between a linear and non-linear jawline shape? That would be very helpful in the designing of my custom jawline implant as I am still not sure what the difference looks like on real people’s faces.

A: The concept of linearity in jawlines is based on the connection between the chin and the jaw angles. A linear jawline shape is when there is a smooth line between the chin and the jaw angle area when seen in the front or oblique views. This is what a custom jawline implant does well if so designed. A non-linear jawline shape is when there is a noticeable inward dip between the chin and the jaw angles when viewed from the front and the oblique views. This is what will most commonly occur when standard square chin and widening jaw angles are used or when a custom jawline implant has a very minimal connection between the chin and the jaw angles. I have attached some picture examples of the differences between these two jawline shapes. Many times models show a non-linear jawline shape because they are  biting down which causes the masseter muscles to bulge outward but it still illustrates the concept. While these model pictures show these two jawline shapes this should not imply that you will have a jawline that looks exactly like theirs does no matter how the implant is designed.

Dr. Barry Eppley
Indianapolis, Indiana

Jaw Angle Implants

Q: Dr. Eppley, I had a buccal lipectomy three months and now my face is slim and less square. I would like to have jaw angle implants to have a wider and more square face again. I have attached some before and after pictures so you can see how my face has changed.

A: Thank for sending your pictures. A buccal lipectomy (bichetomy) should have no effect on slimming the face anywhere but under the cheek area. It does not extend anywhere close to the jaw angle region whose shape is determined by the jaw angle bone and the overlying masseter muscle. In fact the biggest aesthetic problem with buccal fat removal is that it usually has only a very modest effect, and one that is usually underwhelming to the patient, rather than too much of an effect 

But that anatomic issue aside, all that matters is your perception and how you see your face now. I can certainly see the change in your facial shape in your pictures even though I don’t have a good explanation.

Jaw angle implants can be used to make the back part of the jaw wider and hopefully more square. The only question is what size (thickness) of implant to use. Sizes typically run in the 5 to 10mm range.

Dr. Barry Eppley
Indianapolis, Indiana

Skull Augmentation Materials

Q: Dr. Eppley, I am interested in skull reshaping. I want to understand the differences between skull augmentation materials that are used and their risks. Can these materials cause infection, can your body reject it? Also, will they have to be replaced with new ones after a certain period of time?

A: In answer to your skull augmentation material questions:

1) The vast majority of skull augmentations I do are done with custom implants made of a solid silicone material. This materials offers computer designing implants that are both cost effective and can be inserted through smaller scalp incisions.

2) Any implanted material placed in the body runs the risk of infection. That risk for skull implants is very low due to the superb blood supply of the scalp and skull bone. I have yet to see an infection from a custom silicone skull implant.

3) Such materials do not develop rejection since silicone is one of the most biocompatible of all synthetic materials and as a long history of safe medical use.

4) Silicone skull implants are permanent. They do not degrade or break down and thus never need to be replaced. They should not be confused with silicone breast implants which are gel-filled devices and do require replacement in most patients.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Implant Recovery

Q: Dr. Eppley, I have been researching the jaw implant recovery process. However I can’t find much on the recovery from jaw angle implants, whereas there is a lot on what is it like after orthoganthic jaw surgery. Can I take it that the recovery process is the same. For example follow the advice on diet, ice packs, sleeping upright and similar pain levels? I am looking how to best prepare myself after surgery as I am travelling by myself.

A: While there are some similarities in the beginning (swelling) between jaw bone surgery and jaw implant surgery, I would say that jaw implant surgery is not as severe as orthognathic surgery as the actual functional disruption of jaw opening and the degree of trauma to the tissues is much less. Jaw implant surgery disrupts the masseteric muscle attachments while jaw bone surgery disrupts the bone and the muscle.

Pain would be less and ultimately you will recover much faster in jaw implant surgery. It is largely the swelling and the time it takes to go down to look acceptable (2 to 3 weeks) that can be psychologically stressful. Most patients will be on a soft diet for a few weeks and ice is good for the first 24 hours or so after surgery.  

Dr. Barry Eppley

Indianapolis, Indiana