Q: Dr. Eppley, I hope this email finds you well. I have always been self conscious of my small head and weak Jaw. I recently had custom jaw and chin implants placed 7 months ago. I am happy with the results, especially with the chin, but would like to go with something bigger at the jaw with more support at the side between the jaw and chin. I assume I would need an inferior drop to the jaw, where my prior implants had none. I wanted to know how feasible this is to do from a safety standpoint and how the recovery would be compared to the original?
Regarding my forehead, it narrows inward and is concave compared to my zygomatic arch. I saw that you perform temporal implants with amazing results. I just wanted to know if these implants will feel natural once they are placed?
Finally, what kind of costs am I looking at for these procedures? I would want custom implants again for the chin/jaw but I don’t know what you would recommend for the temporal area. I would of course defer to you for both decisions. Finally, how much would these procedures cost in total if done together versus done staged?
A: Thank you for your inquiry. I would need to see pictures of you to give specific answers but I can provide the following general comments.
Since you have indwelling jaw angle implants in place that do not appear to provide any vertical elongation, new jaw angles can be placed. It helps that you have existing pocket so, in theory, the swelling and recovery would be less. (I assume your custom implants are made of silicone. Releasing the implant pocket and dropping the jaw angles down further is not a safety concern.
Based on your description of your temporal deficiency, it sounds like it goes all the way up to the forehead. Thus what you need would be what I call extended and Zone 1 and 2 temporal implants. All such temporal implants are placed on top of the muscle but under the fascia. Patients do not report any problems with such temporal implants feeling unnatural.
As for cost I am a but unclear as to how your current chin and jaw implants were made when you say custom. I assume this was done off of a 3D CT scan. If so that same scan can be used again. I will have my assistant Camille pass along the cost of the procedures if done together during the same surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I was wondering if you could give me your opinion on the use of Aquamid. I’ve noticed in the US it isn’t FDA approved and have read about complications on the use of this injection product. My surgeon wants to use this around my jaw as my custom jaw implants have produced some dents and hollows around the point of the jaw to “fill them out”. However as a patient I am very skeptical on this although it sounds rather straight forward.
A: Aquamid, like all injectable filler materials is straightforward to place. It is just a question of whether the potential problems they can create are equally straightforward to solve.
All so called permanent fillers that create their effects by the placement of non-resorbable particles are prone to their own unique set of problems such as lumps and eventual tissue reactions. While it may never happen, and probably statistically won’t, when it does it will be a challenging problem as the material can not be removed from the tissues. There are many reasons Aquamid is not approved in the U.S. but, even if it was, I would likely never use it. There are numerous other options out there to use to help augment custom jaw implants that don’t have these potential problems or have a better proven track record. (e.g., fat injections, small mesh implants, Radiesse and Bellacol injections)
Dr. Barry Eppley
Q: Dr. Eppley, I have a short lower jaw and feel that it needs improved from front to back. This includes the chin and jaw angles. I am uncertain as to the best way to do it. As a man, I do not lie walking around with a jawline that is not very masculine. My biggest concern about any type of jaw implants is that they might become loose or dislodged if I get hit or participate in any sports. What is your recommendation?
A: There are three different approaches to your type of jawline enhancement and include the following:
1) Standard chin and jaw angle implants (3 pieces)
2) Sliding genioplasty for chin and jaw angle implants (2 pieces)
3) Custom wraparound jaw implant (1 piece)
There are advantages and disadvantages to each jawline enhancement method. Your biggest concern about implant dislodgement would be completely avoided by a single one-piece jawline implant that has a custom fit by computer designing. This is because it is a single implant that with its wrap around effect has more surface area for implant fit and this becomes very difficult to ever move from its custom fit location.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in jaw implants to help correct my facial asymmetry. Although it is not noticeable to others, if taking a picture straight-on and in certain lighting, it shows that my face is extremely asymmetrical. I was wondering if this would best be corrected with asymmetry surgery or could be corrected with customs jaw implants. Also- if corrective asymmetry surgery was performed, could you also add custom jaw implants at the same time to provide the most optimal facial makeover?
A: In looking at your pictures, your facial asymmetry is caused largely by a significantly deviated chin position. This has also has caused some jawline and jaw angle asymmetry although not as significant as that of your chin. There are two approaches to correcting your jaw asymmetry.
The first technique is to correct the chin by a sliding genioplasty that moves it back to the midline. Then the jawline and angles behind it could be augmented by standard jaw angle implants.
The second approach is to go completely with custom implant designs, leaving the chin bone where it is. Computer designing can make jawline-jaw angle implants for each side (that are obviously different but designed to create symmetry) that attach to the sides of the chin.
Either approach can make a big difference and each one has it advantages and disadvantages.
Dr. Barry Eppley
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
Q: Dr. Eppley, I had a question what is the difference between the custom implant and the off the shelf jaw implants? I think for my ideal face I would like to achieve is to vertically lengthen my chin only a bit and make it more wide. For my jaw I think just maybe only a little bit widen but more lengthened so I would have a longer smaller looking face. I think for me its not so nice to widen it too much). I want the same face I have now only smaller looking with a better jawline. I have attached a male model’s photo which is what I want to reach is something like that possible for my face?Also I am a bit concerned if something would go wrong, is it being corrected for free then? And how long should I stay in Indianapolis as I don’t want to know people at home.
A: The role of custom facial implants is useful when off-the-shelf implants can not produce the desired effect either due to the size changes needed, a special shape of the implant is required or there is asymmetry between two sides. Another difference is that custom implants cost a lot more and will add $7500 to a surgical procedure such as yours. So you have to have a real good question to go the custom route.
The model photo you have shown can not be exactly achieved on you because only a custom jawline implant can create a perfectly smooth wrap around effect.
If revisional surgery is needed, the patient is responsible for the costs of the operating room and anesthesia costs. No revisional surgery procedure is completely free.
Most jawline implant patients will stay 2 to 3 days before returning home. But if you are not desiring to go home until most of the obvious swelling is gone, then it will be several weeks. (which is a bit impractical for most patients)
Dr. Barry Eppley
Q: Dr. Eppley, I am thinking about getting a custom jaw/chin implant. I think I have a small chin, vertically small jaw as well as narrow. Since I live in another city I can’t find any experienced surgeon. (or simply one I can’t trust) Would it be possible to get a CT scan done (of mandible and maxilla) and send it to you so you can build a wrap around jaw implant. How much would it cost excluding CT scan and the actual surgery? And then maybe I can find a surgeon in my city who can perform the actual surgery. I don’t want to get a genioplasty. Your help would be much appreciated.
A: Your assessment of your lower face is correct. Your entire jaw is vertically short from the chin back to the angles. Short of mandibular and/or chin osteotomies, a custom jawline implant that vertically extends the lower and chin is needed. That does require a 3-D CT scan which can be gotten in your city. It is then sent to a manufacturer to make a model of either just your lower jaw or your entire craniofacial skeleton. It is off of that model from which I can make a custom wraparound jawline implant. That design in your case is bigger in the chin area and tapers back because the length of your jaw angle is minimally deficient compared to your chin. I can certainly and the total cost to do it is $7500. (cost of model, fabrication and production and sterilization of implant) While you are certainly free to look around to find a surgeon who will place it, my guess is that won’t be easy because they have never seen an implant like that before and may be very uncomfortable (not to mention inexperienced) in its placement. It is not as simple as placing a standard chin implant.
Dr. Barry Eppley
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
Q: I’m very interested in chin and jawline enhancement, particularly the solid one piece custom made framework. I have very little time off these days due to the economy so time off and downtime is of great concern for me. I loved the before and after pictures and would be ecstatic to get rid of my beard which I have worn since I was 19. I have had several other surgeries with great success and am very pleased with their outcome. I look forward to hearing from you.
A: Thank you for your inquiry. There are numerous types of preformed and custom jawline implants, depending upon one’s lower jaw and neck anatomy. Most are three-piece assembled units (extended chin and jaw angles) as opposed to a single-piece unit. The only one-piece unit is when only vertical elongation of the mandible/chin is being done which is the least common.
Whether one can be augmented with available preformed implants or requires a custom approach depends on what one wants to achieve as it relates to the jawline. I would need to see some pictures of you and do some computer imaging of the options to see the differences between a preformed vs a custom approach. The basic difference is that custom jaw implants offer increased augmentation sizes and can create a smooth straightline jawline from the chin back to the jaw angle. There has to be a compelling reason to use the custom approach as it requires a CT scan from which a model and the implants are made and thus costs more.
Whether preformed or custom jaw implants are used, the recovery is no different. While there are few physical limitations afterwards (other than some temporary restricted oral opening), there is considerable facial swelling which takes up to three weeks until it largely passes.
Dr. Barry Eppley
Q: I have a deficient jawbone on my right jaw. I had braces in my teens, but I never had the underlying jaw issue corrected (there is lack of bone on the entire side). My teeth are somewhat slanted to compensate for this (deficient ramus included), and I have a bit shorter jaw on one side. I saw your comment on the custom jaw implant. I have a CT scan and am curious as to the cost of the custom implant. This of course is a cosmetic procedure, and I don’t think I want to suffer another 2 years in braces and jaw surgery when potentially an implant will work out for what I want (especially since my teeth fit very well right now). It does not bother me much, but I could definitely benefit from having more structure to one side of my face, as my chin gives a pointy appearance due to the lack of jawline. What is the estimated cost of a full length jaw implant underneath the bone? I take it this is screwed in? If something goes wrong, can it be removed without damage to the nerves/muscles? Any risks 20 years down the line? Thanks.
A: What is have sounds very similar to a variation of hemifacial microsomia where the one side of the face is shorter than the other, particularly the lower jaw. This cases the bite (occlusion) to be canted upward, the chin deviates to the shorter side and the jawline/jaw angle is less full on that side. The first important question is whether a custom implant is really needed at all for improvement of the right jaw. A common approach is a chin osteotomy to move the chin point to the midline and an extended off-the-shelf jaw angle implant. This may well work fine for you and would obviate the added expense ($7500) for custom implant fabrication. Custom implants are invaluable when nothing else will work well, but more standard techniques with your jaw asymmetry problem may offer similar results.
Dr. Barry Eppley
Q: I read an article on jaw implants in which you wrote “In some cases, no available off-the-shelf chin or jaw angle implant can create the desired effect due to a patient’s unique anatomy or aesthetic needs. In this situation, a customized ‘wrap-around’ jawline implant can be made from a 3-D CT scan of the patient. These can be made as a single implant or in multiple units that can be inserted in pieces and assembled when next to the bone. This approach is particularly useful when the jawline needs to be vertically lengthened. (implant sitting on the bottom edge of the bone)” Can you go into detail about the process of the custom mandibular implant with the 3-D CT scan? And from that how that fits into someone who travels for the surgery?
A: While standard chin and jaw implants will work most of the time, there are some patients whose jaw problem is beyond conventional implant designs. There are also patients who have been successfully implanted but do not like the aesthetic outcome that has resulted. These ‘implant-deficient’ patients have either vertical jawline deficiency, extreme chin deformities or the desire to have a more exaggerated jaw angle prominence. In these cases, only a custom jaw implant will suffice.
The process of making a custom jaw implant begins with the patient getting a 3-D CT scan at a local hospital or x-ray facility. That 3-D mandibular data is then sent to a custom model manufacturer. (I use Medical Modeling, Golden, CO) That model is then sent to me where I will hand carve out of wax or acrylic the desired implant(s) shape. Once approved by the patient, it is then sent to an implant manufacturer who will manufacture and sterilize the final implant(s). It will then be shipped to me for surgical implantation. This entire process takes about 4 to 6 weeks to complete. For someone traveling from afar, they only have to make one visit for the actual surgery. All preparations can be done from afar.
Dr. Barry Eppley
Q: I recently came across an article written by you regarding jaw angle implants for male patients. I went through this particular surgery and I am saddened to say I am not exactly happy with the results. It is a tough situation to be in, but now I realize I should have pursued a CT scan and customized implants, though it was not an option for me or the doctor who treated me at the time. What do you recommend for me now?
A: There are multiple reasons why dissatisfaction can occur after jaw angle implant surgery. The two main reasons are implant size and implant style. Like any implants placed anywhere in the body, they can end up being too big or too small. But that is not the impression that I am getting about your dissatisfaction. Implant style, or how the implant actually changes the shape of the jaw angle, is actually the most common problem. One type of jaw angle implant merely makes the existing jaw angle wider, known as lateral angle augmentation. Most men interested in improving their jaw angle definition, however, don’t suffer from an exclusive width problem. They are interested in a wider and more defined angle which means extending the angle lower as well. That is a different jaw angle implant style, known as inferolateral angle augmentation, and is more difficult to surgically place. Getting lateral jaw angle augmentation when you really need or want inferolateral jaw angle augmentation will only make your jaw look puffy and wide and not get that more sharply defined angle that many men are seeking.
The other jaw implant problem is when one really needs vertical lengthening of the entire lower jaw line but they end up getting lateral jaw angle implants. Vertical jaw implants are ideally made on custom basis for each patient off of a 3-D model from a CT scan. But a combination of an inferolateral jaw angle implant combined with a prejowl chin implant may suffice in some cases. Since you mentioned a CT scan and custom implants, this may be the problem to which you refer.
Dr. Barry Eppley