Your Questions
Your Questions
Q: Dr. Eppley, I think the cheek and infraorbital rim implants that I had placed in 2014 ended up moving upward from the orthognathic surgery I had in 2017. I just noticed this by comparing their current position to the position they were supposed to be in according to the original design, which I’m attaching. I think they are intruding upon the infraorbital cavity and causing some symptoms consistent with nerve compression. I’m worried that they are damaging the optic nerve. Could we have a consultation to talk about this? I think the implants might need to be repositioned surgically.
A:I have seen the IOM implant positions previously. They would not have moved upward from the effects of the LeFort osteotomy, that is just how they were placed. Custom implant placements rarely look exactly like the designs, close but never identical. One of the ‘downsides’ to see a postop scan is that patients can become aware of these discrepancies which exist in every case. The impetus for surgery should be what it looks like on the outside not what it looks like on a scan. It has been almost 10 years since those implants were placed and they would not cause any orbital compression being out of the orbital cavity and only sitting on the infraorbital rim. The optic nerve is located 35mm to 45mms behind the infraorbital rim so this is not an issue.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I think the cheek and infraorbital rim implants that I had placed in 2014 ended up moving upward from the orthognathic surgery I had in 2017. I just noticed this by comparing their current position to the position they were supposed to be in according to the original design, which I’m attaching. I think they are intruding upon the infraorbital cavity and causing some symptoms consistent with nerve compression. I’m worried that they are damaging the optic nerve. Could we have a consultation to talk about this? I think the implants might need to be repositioned surgically.
A:I have seen the IOM implant positions previously on your 3D Ct scan. They would not have moved upward from the effects of the LeFort osteotomy, that is just how they were placed. Custom implant placements rarely look exactly like the designs, close but never identical. One of the ‘downsides’ to see a postop scan is that patients can become aware of these discrepancies which exist in every case. The impetus for surgery should be what it looks like on the outside not what it looks like on a scan. It has been almost 10 years since those implants were placed and they would not cause any orbital compression being out of the orbital cavity and only sitting on the infraorbital rim. The optic nerve is located 35mm to 45mms behind the infraorbital rim so this is not an issue.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have some questions about custom facial implants.
1. How long is the standard recovery process after chin/jaw surgery? Is one week reasonable to plan? Please note, I´m not looking for an exact number of days, only an estimation.
2. The webpages you provided, while helpful in delineating different procedures, do not offer much insight into Dr. Eppley´s expertise vis-a-vis chin/jaw custom facial implants. Hence: how many of these surgeries does he perform per year?
3. What is success rate of these procedures, purely in terms of patient satisfaction?
4. How high/serious is the risk of infection or asymmetry?
5. In the event of infection, does implant have to be removed? If so, will my stay have to be prolonged? Should the new surgery be required – who covers the new expenses?
A: In answer to your questions in regards about custom facial implants:
1. It depends on how one defines recovery. Full recovery with all swelling gone will take a full six weeks. 50% of the swelling is gone by 10 days so a one week recovery would not be realistic in terms of appearance.
2. I perform over 100 semi-custom and custom facial implants per year, more than most any other surgeon in the world.
3. All of these procedures are successful. The better question is how many revisions are performed due to aesthetic concerns. (10% to 20%)
4. I have never seen an infection. Custom facial implants minimize the risk of asymmetry significantly..
5. The expenses of revisional surgery of custom facial implants, for whatever reason, are the responsibility of the patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about custom facial implants. Is there a standard “ideal” facial structure dimension the digital system will use? Will you send me an image of the implant and how it will fit my chin? I would have a scan sent to you. Most custom facial implants are ready in 3 weeks? Is this correct? Thank you!
A: Even though custom facial implants are designed on the computer, the computer does not have any innate knowledge as to what looks best for any patient. It is up to the surgeon to create the dimensions of the implant, the computer software does not do that. It merely makes the implant by the dimensions that the surgeon provides. This is a common misconception by many patients. What the computer software will do is make the implant have a perfect fit, be smooth on its outer surface, adjust for any bony asymmetries and make for a smooth edge transition from implant to the bone. But no software yet can create for the patient some ideal design that will produce the best aesthetic change for the patient.
Custom facial implants usually takes about three weeks from getting the 3D CT scan to having the implant sterilized and ready for implantation. We usually arrange for an actual surgery time once we start the implant design so the surgery process runs expeditiously.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few questions about facial implants:
1. how much will it cost approximately to get customized cheek and jaw implants done at the same time?
2. how long does it take to manufacture facial implants?
3. do you personally use screws to secure both cheek and jaw implants in place?
4. lastly, is it possible to get jaw implants just to have defined jawline without the width being added (meaning that i don`t want for my oval shaped face to change into a square shape but i definitely want the very sharp defined jawline) is it possible?
Thank you very much and I look forward to your response.
A: In answer to your questions about custom facial implants:
- My assistant will pass the cost of custom cheek and jaw implats on to you tomorrow.
- From the time of receiving the CT scan until the implants are designed, manufactured, sterilized and shipped, it would be on average about 6 weeks.
- I secure almost all facial implants with small titanium screw fixation.
- Custom implants can be designed just about any way the patient wants as long as the implants can be made to fit and secured on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a 27 year-old male hoping to improve my facial appearance with the use of facial implants. I have a rough idea of the kind of result I’d like to achieve and have attached pictures below of me now and a photoshopped version emulating the improvements I’d like to achieve. I have no idea whether I can use preformed implants or need to have custom facial implants made.
I’m interested in chin, jaw, forehead and orbital rim implants. I actually have no cheekbones whatsoever either forward or laterally which creates a very unusual appearance, but so far I’ve been using filler for correction.
Please let me know about how I can get these changes, estimated costs involved etc. I would really like to come to you for surgery as I know you are one of the best.
Thanks for your time and I really look forward to your response.
A: Based on your own morphing, the jawline change is absolutely that of a single piece custom wrap around jawline implant. That is the only type of jaw implant that can make a smooth jawline from the angle to the chin as you have shown. The lack of cheek and orbital rims (zygomatico-orbital deficiency) can be managed by two separate implants but a single custom made infraorbital-malar implant is the best implant to make a smooth transition all the way across the orbital rim and into the cheeks in the very thin tissue of the lower eyelids and cheek. What I notice in the forehead is increased brow bone prominence. Again a custom designed implant to achieve that change is always best since there are no preformed brow bone implants from which to choose.
I will have my assistant pass along the cost of custom implant surgery that would cover all these facial areas. It is possible to use a variety of preformed implants in most of these areas and some designs that I have used for other patients. But that is more of a piece meal approach that can be used if necessary but less than ideal for these more complex facial implant changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What is the material used to widen my face at all areas. (especially the area at side from zygoma to lower jaw) Will silicone material be the best ? I have tried fat transfer but it was little volume and only had a temporary effect. I wish to widen my face with permanent and semisolid material. I have attached my photo. Thanks a lot.
A: The best way to permanently widen your face is by using a combined custom facial implants approach with jawline and zygomatic arch designs made from a solid silicone implant material. They will provide an immediate and lifetime change. With a custom design they can be made to match in their upper and lower facial width increases so one is not wider than the other.
Fat injections in you was never going to work. And even if the fat took it would look soft and ill-defined. But most importantly your face is too thin to ever have any fat graft take very well. Fat grafts always work better when there is some natural subcutaneous fat into which they are placed.
The only issue here is that there will be a concavity between the mid- and lower facial widths increases where there is no bone support. I assume this is one of the areas where the fat injections were placed that did not work.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I hope you remember me, I came in for a consultation with you awhile back. At any rate, the procedure I was discussing with you was a custom chin/jaw implant. You are and are still my surgeon of choice/my top pick for this procedure and I wanted to move forward with you yet you was out of my price range. So I found a surgeon locally that was more within my budget and who had done one custom chin/jaw procedure and several pre-fab procedures. But, I think despite our best efforts to ‘play it safe’, and size the implant to appropriate proportions to my face/head, it appears as if we’ve inadvertently gone overboard in at least one dimension/direction of the implant. I’ve just had the surgery in early January so it’s only been less than three weeks. (and of course I realize I’m looking at a good amount of swelling right now). Are you available to consult with me via phone and/or Skype? I’m thinking I may need to redesign another implant, and I’m interested in having you help me in redesigning it. It would be greatly appreciated and I could really use your help.
A: It is extremely common that a patient (if they so insist) or a doctor (who has little to no experience with custom facial implants) unintentionally makes a custom implant too big. While a certain implant design and size make look good on the 3D CT scan model, it can not factor in what it will really look like on the outside when the overlying soft tissues ar covering it. I have made this implant design mistake myself in my earliest days of custom facial implant use. It takes experience to know how certain implant thicknesses impact the final augmentation result. This is why it is so dangerous to take measurements straight from the face and believe that is what the implant thickness should be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to create a more deep-set look to my eyes. That is, the nose between the eyes is not visible in the profile view. I was thinking of having a custom forehead and brow ridge implant to bring them in front of the eyes, and a Le Fort II osteotomy to bring the nasal bone forward to create a result like so in the after:
Would this be possible? I mentioned the Le Fort II osteotomy since I would like to significantly bring forward the flat mid face, including the base of the nose, which is not done in a Le Fort I osteotomy or paranasal implants.
A: A custom forehead/brow bone implant can be done and would be the most successful approach to augmenting the upper third of the face. However, unless you have a malocclusion which requires a maxillary advancement, and even if you do, a LeFort II osteotomy is not really a great approach for midface augmentation. It is the most difficult of all Lefort osteotomies to perform (getting clean osteotomy lines) and the resultant augmentation above the LeFort I level does not usually justify the effort. (in other words, it is a long slide for a short gain) It would be far better and effective to create a custom midface implant for the entire nasmasomaxillary region even if one is having a LeFort I osteotomy. It is simpler and more effective than trying to move the bone at or below the infraorbital rim/nasal side wall areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m currently in the midst of orthodontic treatment and I’m scheduled for some surgical palatal expansion and double jaw surgery later on (Lefort I). I have recessed maxilla and mandible bones, so they will both be advanced (after my palatal expansion is complete).
I also have a midface deficiency. I have a tear trough deformity and scleral show. I believe that a LeFort III would work for me, but I have to be realistic because it’s very invasive. I don’t suppose I’ll be able to find a surgeon to perform such an invasive operation on me – which is why I would like to ask if a malar osteotomy and some kind of orbital rim procedure after my jaw surgery would produce the same results as a Lefort III – filling out my midface, making my cheekbones more prominent, and correcting scleral show. Do you offer those procedures?
A: There is no question that a simpler and more effective treatment to your upper midface concerns is NOT a LeFort III but custom orbito-malar facial implants. They would provide a much better result than trying to move the bone and are made from a 3D CT scan and could be done after your orthognathic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in custom facial implants to correct asymmetry and deficiencies from previous corrective jaw surgery. My case is completed in that I have significant nerve damage on the left side and an existing Medpor jaw implant on the same side that doesn’t address the problem.
A: Your description of your mandible/chin concerns is complicated but that is what makes it only treatable by a custom implant approach. Using a 3D CT scan, the shape of the lower jaw can be clearly seen with all of its asymmetries and deficiencies as well as a clear view of the indwelling Medpor implant. An implant can then be designed, most likely as a single piece that wraps around the jawline, after the computer removes the Medpor implant. Surgeries like yours are challenging due to scar tissue and the never easy removal of Medpor but can be very successfully improved with the aid of a custom facial implant approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had custom facial implants placed recently and it looks like they’ve been infected and need to be removed. The initial cost for these implants was $5500. Assuming I would like the same set manufactured, would it incur the same charges? Lastly, if I wanted them slightly modified, would it be considered starting over from scratch, and would I have to pay the full fee again?
A: Fortunately, I have never had a set of custom facial implants get infected but I have had patients who want to modify their existing custom facial implants for new ones for aesthetic reasons. In these circumstances, I have had the manufacturer (Implantech) make new ones at a reduced fee over the original implants even with a few modifications of the original design. The manufacturer has no obligation to do so and whether that is a universal policy I do not know. Each case with any surgeon must be determined on an individual basis in discussion with the manufacturer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had custom chin and jaw angle implants placed four months ago and then I had them revised with new implants two months ago. While it is much improved and is almost what I want, I think I need another surgery. How soon should I have another jawline implant surgery again, I am ready right now?
A: While I am not your plastic surgeon, I do not agree with any patient changing their facial implants repeatedly over very short times. Making facial structural changes before 9 to 12 months short of some major aesthetic problem is often premature. You have been through two surgeries over a short postoperative period of time and now you want to change the look again…before you have ever truly seen the final result and before you have had time to psychologically adjust to your new look. Perhaps you have learned that, despite all the preoperative predictions and planning, that it really isn’t the look you want or maybe achieving that look isn’t even possible. I am not looking for an explanation nor do I want one from you as to the logic of the desire for another surgery, it is just this decision just seems very hasty sitting from my perspective.
The other equally important reason that I advise against prematurely jumping in and changing facial implants is that each surgery carries risk and the more surgery you have the greater likelihood that one of those risks will occur. Every surgery always involves some form of a trade-off and each new surgery creates the opportunity for a new problem to appear. The dreaded one, of course, is infection. Just because it has not occurred before, each new surgery involves a new spin of the wheel so to speak, and repeated surgeries increases that risk.
I say all of this because a patient’s decision to undergo any revision should be based on the severity of the problem versus the degree of risk involved. There does come a time when the balance between those two should give one pause for reflection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 22 year old man who is interested in custom facial implants. I have taken an interest in your practice because of your really detailed and informative website and photos and because of the experience you have with the particular facial implants I want done. I am interested in getting cheek and wraparound jawline/chin implants. I want the cheeks implants because my cheeks are quite small and I would like to have implants put in to make them larger and have a more sculpted face. As for my jawline and chin, it is quite small and narrow and I would like a wraparound jawline implant to give me a stronger wider jawline, a sharper jaw angle in the back, and a larger chin that are seamlessly connected together. I know this will require a custom implant approach to get the best implant symmetry and shape, provide a faster operating time, and provide me with a better chance of obtaining the results I am looking for. I want to know if these two surgeries could be done at the same time? I am really looking for a more masculine sculpted jawline and chin and cheekbones that provide a youthful face as well. I am really interested in you performing the surgery since so far you seem to be the only surgeon I have searched online who has a blog devoted to helping answer clients questions and you have an extremely thorough website.
A: You are correct in assuming that a custom facial implants is the best way to go when one seeks a wrap around jawline implant that is seamless from front to back. While off-the-shelf cheek implants could probably be used, one might as well make the cheek implants custom as well since that would add little cost as the 3D CT scan and software design process is already in place. It would be very common to do cheek, chin and jawline implants together to achieve a comprehensive overall facial enhancement result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom facial implants. I currently have a jaw/chin implant in place which I want removed and replaced with a wrap around, custom made jaw implant (and possibly a cheek implant replaced). Is this possible to do as one surgery, I was diagnosed with a mild case of hemifacial microsomia, so my cosmetic procedures were focused on only one side. I had a single jaw angle implant placed on the left side, and 1/2 of a chin implant with an extending wing place on the left side as well. I also has cheek implants placed on both sides, and one appears to be much more prominent than the other post-op. All of these implants were done during one surgery, and I believe they are all silicone implants. I would like to create more symmetry and balance in my entire lower face, and provide more jawline definition while maintaining a feminine look (no squareness in the jaw, as the left is now).
A: With your history of congenital facial asymmetry and an attempt using standard stock implants, the only way to really make significant improvement is to have custom facial implants made. With the computer, all bony asymmetries can be precisely corrected and precision fit of the implants can be obtained. You probably have a very good result from the prior surgery but it just shows the limitations of using standard-sized implants for a face that is not normally formed. (asymmetric)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. Roughly what is the cost of a Custom Jawline Implant and the procedure if I want a very large implant enclosing the entire chin and jawline and angles, adding quite a lot around the angles, increasing chin projection up to 25mms?
A: A custom jawline implant is fabricated from a patient’s 3D scan. From this a completely customized implant is made from one jaw angle to the other. While any dimensions can be made on the model using design software (up to 25mms at the chin), there has to be enough soft tissue along the jawline so that the implant will actually fit into place. Realistically, having placed many custom wrap around jawline implants, a chin enlargement of 25mm horizontal advancement is likely more than the neck soft issues (which is where the skin must come from) can accommodate. This is too much soft tissue stretch when you factor in that the implant wraps the whole way around the jaw. A more reasonable approach is around 15mms or so of horizontal chin advancement. You must also factor in the lower lip position and the depth of the labiomental sulcus which will be severely left behind when the chin comes that far forward. The total cost of such an implant, all costs including fabrication and surgical placement, is in the range of $12,000 to $ 13,000.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I visited a craniofacial surgeon for advice because my right zygoma is lower, depressed and flat while the left one is just perfect (high, round, nice projection, and I want to leave it like that without surgical approach) He than diagnosed me with hemifacial microsomia. I asked him about the option of a custom implant on the right zygoma to make it just as high, round and projected as the left one. He than said it is a bad idea to use implants for several reasons that sound convincing but proposed to use Beta-tricalcium phosphate granules trough a surgical approach to achieve the symmetry. He said it will act like an implant and also be permanent. He is a very well known surgeon and I do trust him, but I can’t find alot about this approach and that kind of worries me a bit. Are those granules really able to bring the zygoma (not the arch) forward?
A: The use of hydroxyapatite granules (or beta-TCP) in craniomaxillofacial surgery is an older approach for bony augmentation. It has a long history that dates back to the 1980s when hydroxyapatite blocks and granules became commercially available. I used it fairly frequently back then myself as there were no other non-bone material available. While it is a more ‘natural’ material, injecting/placing granules is an imprecise and relatively uncontrolled method of augmentation. For small amounts of augmentation that do not require a precise shape, it may still have a role in some select circumstances. But a ball of granules placed on the bone is easily compressible and displaced and defies being able to be accurately shaped. I have no doubt HA granules will provide you some augmentative benefit but it will not be effective in getting the most accurate and symmetric result to your normal side. It is simply a matter of the limitations of the material’s properties. The use of HA granules today is usually limited to older craniofacial surgeon’s who still have the historic belief that any synthetic material is ‘bad’. As for achieving perfect bone symmetry in the face to an opposite normal side, it is impossible to rival a custom computer-generated implant approach that creates the perfectly-shaped implant down to fractions of a millimeter. Such an implant on the zygoma/zygomatic arch is really conceptually the same as any other synthetic implant used in cosmetic cheek augmentation. I fail to see what makes that approach ‘bad’.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I previously had cheek and jawline reductions to create a slimming/narrowing effect to my face. Unfortunately the surgery has had adverse consequences and has overly feminized my face. I no longer have a square jawline and I find that the height is much too high at the rear portion of the jaw creating a very slim and weak jawline. The angle at which the jaw was cut is too straight which portrays a more unnatural look that seems to elongate my face. Custom CT scanned jaw implants seem like the logical response to the amputation of the bone. My questions in regards to this matter are related to muscle and tissue reattachment as well as unforeseen complications. Would detachment of mandible muscle and skin tissue create any issues? I am constantly concerned with sagging skin after performing my initial surgery. Where would the jaw implant gain the needed skin envelope? Does the skin tissue come solely from the neck or would it also pull and realign from my lower cheeks? As for my cheeks, there are multiple irregularities in regards to my mid-face after the cheekbone reduction. I am most curious as to what procedures could correct these irregularities. As my initial surgery was to primarily address the width of my cheekbones, I would not like to add much more. Could I address the problems without adding more width?
A: I have had the experience of seeing numerousI have see men with the exact situation that you have. It is corrected by computer designed jaw angle implants that restores height but virtually no width. It is a unique-shaped jaw angle implant. It gets its soft tissue coverage by recruiting tissues from the face rather than pulling them up from the neck. Like the jaw angle implants, any cheek implant restoration is done using a 3D CT scan where any implant fabrications are done on the computer and can be perfectly corrected for any asymmetries as well as limiting any significant amount of width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, You suggested 10mm of vertical projection for both my jaw and chin. However, when I measured my face with a ruler, I determined that in order to achieve the 1/3 1/3 1/3 ratio, I would need between 15-20mm vertical lengthening. I am hoping we can design a chin implant that has close to 15mm of vertical length. In my experience am more worried about undershooting than overshooting. Is a 15mm vertical chin possible? If so, does it carry increased risk?
2) Can we use computer imaging to figure out the ideal dimensions? My left jaw projects significantly more than my right jaw.
3) With a custom 3-piece chin + jaw set that includes both vertical and horizontal projection, will there be a smooth transition in the space between the chin and jaw(body)
4) In terms of safety, what is the difference between my current Medpor implants and silicone? I heard that silicone breast implants may rupture.
5) Can silicone be flexibly shaped to my jaw contour using hot sterile saline the way Medpor can? And if so, would that mean that the easiest approach is to use a previous patient’s custom implants, and skip the CT scan?
6) How much vertical lengthening do my 7mm Mandibular Matrix jaw and chin implants already have? I can’t find the vertical jaw dimension online.
7) Since my current Medpor implants have been screwed in, how will you remove them? Do you “unscrew” them? I believe there are two screws anchoring each one of the pieces.
8) How many custom combined jaw+chin procedures have you done in the past? Are you the only one who does this?
A: In answer to your questions:
1) The vertical length of the jaw angles can be lengthened in the range of 15 to 20mms. The chin can not be done as much because of the lack of adequate soft tissue to recruit for coverage. A more realistic lengthening in 8 to 10 mms.
2) 2) Computer imaging is great to provide a general concept or trend but it would not be an accurate way to determine the desired millimeters of change. Unless the picture is taken so that the computer recognizes its size, it can not be used for estimating exact changes.
3) One of the main purposes of a custom 3-piece jawline implant system is to have a smooth transition between the chin and the jaw angles.
4) There is no danger is using silicone as a
facial implant material. It is a solid material unlike silicone breast implants. I ma not sure where you would get the concept that a silicone facial implant would rupture.
5) Silicone always adapts better to the bone than medpor. Medpor is a very stiff material that is minimally adaptable using ‘hot water’. This is not necessary with a silicone material.
6) It is impossible for me to say how much vertical lengthening your current implants provide since that is highly influenced by how they were placed in addition to their design.
7) Your current implants have to be unscrewed…that is the easy part in trying to remove them.
8) I have been making custom facial implants for 20 years. I can’t speak for who else may use this approach around the world.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I had submitted this question via the website, but never received a response so not sure you received it. I had a sliding genioplasty with you probably close to 2 years ago now. I am interested in further enhancing my jaw and chin. I know the sliding genioplasty was brought forward as much as possible, but I am looking at the possibility of a custom jaw/chin wraparound implant as I a.) want to move it even more forward and b.) want it to appear that the entire jaw has been augmented rather than just the chin. I also want to widen things as I think the sliding genioplasty makes me lower face appear much narrower. I wanted to find out how closely this could resemble my having jaw surgery (I do have a class II malocclusion, but jaw surgery would be more complicated in my case). By this approach, how much further forward could the chin/jaw be brought by an implant? I know it is a much more expensive approach than off the shelf implants, but they are not going to help me I don’t think due to my unique problems. If I sent you a current picture, could you demonstrate to me what this would look like from the front and side?
A: This is the first I have seen your question. To create a wider and more prominent entire jawline, you are correct in that some type of wrap around implant approach is needed. The question then becomes whether it is done best by off-the shelf-implants (square chin and lateral augmentation style jaw angle implants) would suffice or whether a custom chin and jaw angle implant approach is needed. I would need to see some pictures of you currently, do some imaging, and see exactly what type of changes would be satisfactory. Please send me a few pictures at your convenience.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am looking to improve my weak jawline. It is weak not only in the front but all the way to the back. I guess I was just borne with a small underdeveloped jaw. It makes me look very unmasculine and I would like to improve that as I think it would make my life better. I have read about implants that are used for the jawline but it is not clear to me whether I would need custom implants or not.
A: Facial augmentation can be done by a variety of implant approaches which fundamentally breakdown into off-the-shelf, semi-custom, or custom. Off-the shelf implants mean what is currently available in the catalog that the manufacturers have available and can ship with arrival in 1 to 2 days. A semi-custom implant approach means using what is available off-the shelf but modifying them during surgery to fit the patient’s anatomy and their aesthetic desires. Like off-the-shelf implants, they can be ordered and arrive in 1 to 2 days. A custom facial implant approach is very unique because the implants are made off the patient’s model made from a 3-D CT scan either by hand or computer-generated. These take a certain amount of time to manufacture, which at the minimum is three weeks from when the patient gets their CT scan done locally.
To make the determination of which implant approach needs to be done for any particular patient I use computer imaging to get a feel for the magnitude of facial implant volume and changes that is needed.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I would like to have jaw angle implants placed on both sides. Even though I have jaw angle asymmetry, getting custom implants is currently out of my budget. Do you think I could still get great results with doing a CT scan and having you pick “off the shelf” implants based on my CT scan? Or would I be better off coming back in a year or two after saving up? Also, what about the possibility of using this “artefill” permanent filler instead of an implant? Do you have any experience with that?
A: What you are referring to is using a combination of a your jaw model from a CT scan and using off-the shelf implants to get the best result. That is what I call a 'semi-custom facial implant' approach in which the stock implants are modified before surgery on the model. An advantage with this approach that you do not have in surgery as you can never see the jaw angles in full detail and certainly can't really compare their anatomical differences. A semi-custom approach is reasonable if the anatomical problem is really one of asymmetry and the changes desired do not exceed what off-the shelf implants would normally do. In other words, you can do some adjustments to the shape and size (reduction) of the implants but you can't add to them. If one is looking for changes that go beyond the scope of existing shapes of current implants then only truly custom-fabricated implants will do. My perception is that you probably fit more into the semi-custom jaw angle implant approach.
As for 'permanent' injectable fillers, that does not really exist. No injectable filler, Artefill included, is a permanent filler. (if you do it enough times, some permanency of the result will occur due to its non-resorbable PMMA bead content) But on a practical basis, and I will assume that you can get a similar result to a facial implant (which you really can't), the cost of the filler based on volume needed will have allowed you to have had custom facial implant surgery…for a result that is not equivalent. The real role of injectable fillers as a substitute for facial skeletal augmentation is a temporary trial to see if augmenting any facial skeletal area is worth actually having the real surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about 3D-generated chin implants. I have read that a perfect implant can be created without the trial and error process through the Implantech company. When reading further I don’t know if it means it reproduces exactly what you have crafted or it reproduces a perfect chin implant based on the dimensions of the face. Could you please clarify?
A: a 3D or custom facial implant must be made off of a skeletal model, whether that is off of a 3D CT scan or an actual hand-held model that is made from a CT scan. Either way, the implant is made based on the surgeon’s specifications/dimensions and it is ‘perfect’ because it matches exactly what the surgeon envisions. It is not perfect because the computer or its software have some method of knowing how to make an implant that would look the best based on how the patient’s face looks or its dimensions.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, how big can custom facial implants be made? Can I get any size and shape that I want? I know you design a lot of facial implants for people having read your blogs. You talk about how it is better to be more conservative than extreme for many patients. Why can’t I just get any size facial implant I want?
A: I have make these comments in my writings based on a lot of experience with men trying to design their own implants or providing me with very specific dimensions of what they want. I have seen too many cases where such outcomes have resulted in the need for revisional surgery because the outcome turned out to be different than they thought it would be based on its size and/or shape. I am always happy to accomodate patient requests and provide implant dimensions that one may desire, but I do so with the understanding that they then take responsibility for the outcome should the implant be too big or oversized. I make implant suggestions/recommendations based on my experience of seeing how a lot of facial implants turn out afterward as well as knowing the technical and tissue limitation difficulties that can come when trying to place large facial implants. While one can design anything on a 3-D model, that doesn’t always mean that the overlying soft tissues can equally accomodate its size. Custom implants must be designed with an appreciation of more than just how they sit or look on the facial bones.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, if a patient seeks to duplicate a jawline of an existing person via the use of custom implants, assuming their current structure and soft tissue allow for that look, how closely do you work with the patient to design the implant? What sort of process do you use to make the implant provide a look as close to the desired person as possible?
A: When it comes to designing custom facial implants, I have done it from numerous different approaches. Many patients do not want to participate in the details of their implant design, but some patients do. I do not profess to have an exclusive skill or knowledge in how to predict how any implant shape and size may affect the way the face will look once it is implanted, so I am always open to input. I have even done a few cases where I let the patients completely design their own implants out of clay, only providing input as to details that may make a certain design or size difficult to surgically place. Obviously I have tremendous experience in seeing how different implant shapes and sizes affect the face. But I appreciate that a patient providing input about their implants does empower and invest them in the process. On the flip side of that investment also comes partial responsibility in the outcome of the facial implant procedure, particularly if the results are less than desired.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about custom jaw implants. First, can they not be made of Medpor material as opposed to silicone? Secondly, what is the limit of vertical lengthening of the chin. I have read that if you lengthen it very much you will disrupt the mentalis muscle sling. How do you determine the maximal limit?
A: In answer to your questions:
1) Medpor is a machine milled product, silicone is a poured product. Since custom implants are made out of molds from hand-carved clay designs, the implant material must be poured into a mold to be made. In addition, ,many custom facial implants designed are large with complex shapes, the use of silicone material which is very flexible makes it possible for them to be inserted through many traditional small incisions, particularly from inside the mouth. Medpor is a rigid material which would make it impossible to place many custom implants. It is hard enough to place many standard Medpor implants, the need for a two-piece design of the chin implant is an example of that material problem.
2) In my experience, the limit of vertical elongation of the chin area is a function of the skin stretch more than ‘disrupting the mentalis muscle sling’. I have rarely found the need to go beyond 10mm to 15mm and have no found it to be a problem. The key to inserting such an elongating implant in the chin area is the location of the submental incision. If you use the traditional incision location, its position will be displaced outward up on the edge of the rather than under it. Therefore, the submental incision must be moved back from the traditional location when using a custom chin implant that creates substantial vertical lengthening.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have indentations/notching at the sites of my previous mandibular osteotomies. (sagittal split advancements three years ago) I want to get implants to build the bone back out as well as make my jaw angles more prominent. Given the differences between the two sides, I think I will need custom-made implants. How are custom implants made? Do you secure them to the bone somehow so they do not move afterwards? How painful is the procedure?
A: In answer to your questions:
1) Custom are hand-made off of a 3-D model obtained from a CT scan of the patient’s mandible.
2) All facial implants are secured to the bone by screws.
3) Since you have had a prior mandibular osteotomy that is a good reference point point to discuss pain and recovery. Suffice it to say it is less than that process although there are numerous similarities such as the area of facial swelling and the temporary issue of some mouth opening restriction. But if sagittal split osteotomies are a 10 on the scale of pain/swelling etc, jaw angle implants by comparison are a 2 or a 3.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was thinking if I would be a good candidate for a custom implant? I had a chin implant done two years ago but had it removed six months later because it did not look and appeared unnatural and asymmetric. This time, I want the implant to address the asymmetry of my chin and also add length and width to my jawline while also lengthening my chin. I have attached pictures to try and show you what I’m looking at getting resolved. Also, are custom implants significantly more costly? My left side of the chin is about 3-4 mm shorter than my right side. Also when I feel where my chin transitions to my jawline, there is more of a “dip” in the bone on my left side. I would like a more smoother jawline transitioning to my chin and a more prominent jawline on both sides as well. I have outlined the area of jawline I am referring to and that I would like it both extended horizontally and vertically. I have attached the picture of my previous implant to show the increase in asymmetry that the implant caused. I think the asymmetry caused the implant to not fit snug and was also the reason why I was able to move the implant from side to side even months after. And finally I have re-attached the ideal chin and jawline. I think what i’m looking to fix would give me the desired look.
A: Based on your pictures and your good illustrations, the only way you would get that chin result is with a custom chin implant. There is no off-the-shelf chin implant that would have those exact dimensions and shape. Why your first chin implant resulted in that undesired look is not known to me because I don’t know what style and size of chin implant it was. It may have been inappropriate for your chin based on a variety of factor6s including style, size and technical placement of the implant.
That being said, there are three ways to go about getting a ‘custom chin implant’. They are different because of how they are done and their cost.
#1.The least expensive way, because it costs no more than a standard implant, is to select a certain chin implant style and size and custom carve it either before and during surgery based on the illustrations you have shown. The limitation is that it is an approximation of the underlying chin anatomy.
#2 The second way is to get a 3-D CT scan and have an exact mandibular model made. From that model, I can then take an off the-shelf implant and then carve it to shape by placing it on the model. This is better than #1 because we would know the exact chin anatomy. The limiting factor is how close existing chin implants are to your needs. Besides the cost of a 3-D CT scan of your mandible (which your insurance will likely cover) is the cost of having the model made. ($ 1100)
#3 The most ideal way to get a custom chin implant is to take the mandibular model and I will then hand-care out a completely custom implant which will then be sent out for formal implant manufacture. The total additional cost of this approach is $3500
As you can see there are multiple ways to get a custom chin implant. But when it comes to having a chin implant that blends smoothly back along the jawline, a true custom chin implant is the only way to get that result in most cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I believe I need jaw implants from the gonial to the chin area. I have had a sliding genioplasty at the chin several years ago. I have a short jaw bone that angles upward from the chin area to the bottom of the ear. I need to bring this to a more horizontal angle.
A: Thank you for your inquiry. It sounds like you have a pretty good handle on what you need. Ideally you need custom jaw angle implants that extend from the jaw angle right up to the chin area. Such an implant is not available as a stock or off-the-shelf implants. Off-the-shelf jaw angle implants will not reach the chin area, at best they will reach to the mid-body of the mandible behind the cut or notch from the prior osteotomy. That is an acceptable approach if one can accept an indentation between the chin and the jaw angles. But a completely smooth transition from the chin back to the jaw angles requires a custom implant approach based on a 3-D model mandibular model made from a CT scan. This is the best and only way to get a jawline that is completely harmonious fro one side to the other.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a chin implant which was done four years ago. Now I want to get a jaw angle implants to achieve a subtle outwards projection and a slight vertical projection such that the lower 1/3rd of the face becomes ever so slightly longer in the back. I only want subtle changes and do not want a very prominent square jaw. Instead, I want to retain the V shape ending of my lower 1/3rd of the face but just slightly stronger. Am I correct to assume that this can only be achieved through custom implants?
A:You are not correct in assuming that custom jaw angle implants would be needed to achieve your goals. While they could be done in a custom fashion, it would be more cost effective to modify existing stock jaw angle implants. Custom facial implants are almost always done when the size of the facial projection needed exceeds those implants which are commercially available. You are going the opposite and more favorable direction. Based on your description, I would recommend Medpor RZ jaw angle implants, small, which could be intraoperatively modified to 3mms lateral width extension and 5mms vertical length extension. That is about the size to me that you are talking about when you mean subtle increase in jaw angle projection.
Dr. Barry Eppley
Indianapolis, Indiana