Your Questions

Q: Dr. Eppley, I am interested in custom jaw angle implants. Could Porex implants be removed and replaced with custom made ones from three 3 years after surgery? I had porex jaw angle implants placed to restore my jaw bone deformity after jaw reduction surgery. But I’m not happy with that result. I realized now that off-the-shelf implants do not suffice in my case. So I have decided to make my implants removed and replaced with custom jaw angle implants. But a long time has passed since the implants were placed. I have heard it is very difficult to remove Porex implants especially after years. The doctor who did the surgery to restore my jaw angle with Porex implants said… You would risk damage to the masseter muscle which has already been manipulated by your previous surgery when trying to remove them. He told me that he found the left side of my jaw muscle was torn by the careless reduction surgery. In this worst scenario, Is it still possible to remove and replace them? If it is possible how much cost it? I hope your reply soon.

A: I have removed numerous Porex jaw angle implants and, although it is far harder than removing silicone implants, it can be successfully done. You would be correct in that a custom jaw angle implants would be the most effective jaw angle restoration method now. I do not think that the masseter muscle would be any further damaged by the implants removals. Where the implants are most adherent to is the underlying bone. They do peel off of the muscle without a lot of difficulty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking to obtain some information about posterior jaw or jaw angle implants. I had three surgeries approximately 20 years ago on my upper and lower jaw to correct the alignment and preserve my teeth.  After I healed from my last surgery I was to have jaw inlays placed however I did not opt for it at that time due to the need for external incisions. Attached you will find several photos from today and one from (many years ago) just prior to my maxillofacial surgery to give you an idea of how my face once looked. What is the approximate cost for the entire procedure?  I’m looking for an approximate amount for the entire process, from beginning to end.  Does having previous maxillofacial surgery have an impact on this procedure?

A: Undoubtably you have as one of your orthognathic surgery procedures sagittal split of the mandibular ramus (SSRO) osteotomies. In some cases this can cause some partial resorption of the jaw angle particularly if it was done more than once. You can clearly see in your before and after pictures that have lost the shape in the back part of the lower jaw. (loss of angles) While jaw angle implants is the correct procedure for jaw angle restoration, your prior surgeries have undoubtably caused some uncommon and uneven posterior jaw anatomy. To get the best result in terms of shape and symmetry you would be best served by custom jaw angle implants made from a 3D CT scan. That would not only show the shapes of your two jaw angles before surgery but would allow the computer design to make right and left angles that would match. While standard jaw angle implants would be better than nothing there at all, there undoubtably would be some persistent asymmetry. What is unique about restoring lost jaw angles is that a significant portion of the implants has to lie off of the bone. So custom making and fitting of the implants to the altered anatomy (with the use of microscrew fixation) would be invaluable in terms of implant stability.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you for your website which provides an extremely useful series of information on most areas of plastic surgery.

In relation to custom jaw angle implants, I understand there are a number of choices of material including MEDPOR and Silicone. If one is going to carve custom lateral jaw angle implants, to account for hemifacial microsomia, what sort of durometer of silicone is the best to use in this area – soft, medium or firm? Clearly, one would not want the same sort of flexibility or softness that one would expect of a breast implant for example, in the jaw area. Also, which material is better to use, silicone or MEDPOR?

A: When it comes to custom jaw angle implants, there is currently only material that is available to be used…silicone. It is my understanding that custom facial implants are no longer available as the manufacturer has chosen not to provide that service anymore. In using silicone for facial implants, the standard durometer would be firm or extra firm. Even the softest durometer for facial implants is much firmer than what is used in silicone gel breast implants. (that is for a soft tissue reconstruction not a bone reconstruction)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want custom jawline implants placed.  I want to know how difficult the operation is to place custom Medpor jaw angle implants? I have had two surgeries, a bilateral sagittal split ramus osteotomy with genioplasty and an inverted ramus osteotomy to correct the sagittal split osteotomy. Even though I have custom Medpor jaw angle implants already fabricated, I am not comfortable with my current surgeon to place them…I want to know if you would be able to take over the case? What is the risk of infection? Thanks in advance.

A: Custom jawline implants have many advantages over standard shaped implants, particularly those made of Medpor material as they are more difficult to shape during surgery. Medpor jaw angle implants, and medpor implants in general, have a higher risk of infection because of their porous properties than that of smooth nonporous silicone. Thus these implants must be handled with great attention to detail. The implants must be impregnated with antibiotics, and that is important and easy to do, but the far more important issue is adequate soft tissue coverage over them. This requires careful dissection of the tissue flaps over the jaw angles and great attention to a water tight closure. Having had two prior procedures before, this makes this pocket development and closure more challenging due to scar but, in my experience, can still be done very successfully.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can jaw angle implants be custom made out of Porex? I had Porex jaw angle implants placed to restore my jaw bone deformity after jaw reduction surgery. but I am not happy with the result. I realized off- the self implants do not suffice in my case. I am considering my implant removed and replaced with custom made ones. All I have seen of custom made implants is to be made of silicone. Is it difficult to make a custom made implant out of Porex or too much expensive?

A: Quite simply, the manufacturer of Porex implants  is not willing to make custom jaw angle implants. This is undoubtably because the Porex material has to be machined (milled) to create the implants which is both time-consuming and expensive. Conversely, silicone implants are poured into a mold which is far easier to manufacture and more economical. It sounds like you had jaw angle reduction surgery (amputation of angles) and then had them restored by jaw angle implants. I have seen this scenario numerous times. It may be that only custom implants are an appropriate solution for your problem or it could be that the implants you have in place have either not been the right style or not well placed. Medpor (porex) jaw angle implants are notoriously difficult to properly position. So unless your surgeon has tremendous experience in doing jaw angle implants the problem may be in the implant selected or how it was positioned. Unless you have a 3-D CT scan of your face/jaw done it would be hard to know what the real problem is.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had orthognathic surgery of my upper jaw 2 years ago. My upper maxilla was impacted (5mm), advanced (5mm) and moved to the right (2mm) with a Lefort and lateral segmentation of my upper jaw. I got cheek implants, a mentoplasty without implants and jaw angle implants (porex) in standard size. I want my jaw angle implants removed and replaced as I am not happy with the results. My surgeon did a second surgery to try to file the existing implants and create more symmetry (one side is longer than the other with the implants) but even then the result is not good and the only thing to do is to remove the porex implants and replace with custom made. In addition to asymmetry I find that there is not a nice jaw line between the implant and my chin (not continuous line) which create a strange visual effect (it feels that the jaw implant should have continue to meet with my chin). To me is very important that the surgeon that is going to perform the surgery is both knowledgble and has a ‘cosmetic’ eye. I wish to have advice of how difficult this type of corrective procedures are.

A: I am not surprised that revision of porex jaw angle implants did not improve the problem. They are virtually impossible to merely ‘file’ in place due to their harder plastic structure. In addition, it is very common to have some disruption of the jawline between the chin implant and the jaw angle implants, particularly if the jaw angle implants created any vertical lengthening.

While I don’t have the advantage of knowing what your face looks like and an appreciation of skeletal anatomy, I can make some general comments. Removal of porex jaw angle implants is difficult but far from impossible. I have removed such implants numerous times. The question is how best to replace them. There is obviously a reason you had them placed initially whether it was for angle definition, widening or vertical lengthening. Such desired changes would be important to know. It does not appear that standard jaw angle implants may suffice. Custom jaw angle or jawline implants are made off of a 3-D skeletal model. They can be made in any shape and size based on needs and are fabricated out of silicone not porex. Placing the new jaw angle implants is no more difficult than the insertion of the initial jaw angle implants.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  two months ago I received surgery which was to rebuild my jaw bone deficiency due to prior jaw reduction surgery. This was done with jaw angle implants placed through the mouth. But I am not satisfied with the result. I have heard of custom made implants? Can I get to my previous appearance by using this method? If it is possible, how much does it cost? And can the Medpor jaw implants with screws be removed?

A: There is no question that custom implants made off of a patient’s mandibular model is the best way to get whatever desired jaw angle shape one wants. Nothing can be more accurate than premaking an implant for the exact defect. Off-the-shelf implants, while successfully providing a new look in many cases, do not work well when one is trying to restore their original anatomy. That is not what they are made for. I have removed/modified many Medpor jaw angle implants, and although they are certainly not easy to remove, it can be successfully done. The sooner they are removed after placement the better but even if in place for years they can still be successfully extracted.

The cost of manufacturing custom implants adds about $3500 in addition to the overall cost of jaw angle implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have a very high jaw angle. My goal is to have a jaw implant that will lower my jaw angle as much as possible. The problem is that the biggest implant I have seen only has 35mms of vertical length and the inferior ridge is just under 10mms. Does a bigger jaw angle implant exist and I have just not seen it? If not, how can a bigger one be made if possible?

A: Your are correct in your assessment that no off-the-shelf jaw angle implant can drop one’s angle down anymore than 10mms at most. Anymore more than that requires a custom implant to be made which can bring it down closer to 20mms. Such exceptional jaw angle extensions are uncommonly requested or needed which is why no stock implant exists with that degree of accentuation. I have made custom jaw angle implants that do achieve what you are after. They require a jaw model to first be made which is done from a 3-D CT scan of the patient. The jaw model made is then the exact anatomy of the patient from which the design and model are created.

Dr. Barry Eppley

Indianapolis, Indiana