Q: Dr. Eppley, I am a 25 year old male. I’ve had a septorhinoplasty, a chin implant and orthodontic treatment previously. I feel that my previously under projected chin and jaw development are inter-related, however, given that I am fairly satisfied with my corrected bite and improved chin projection, I am interested in augmenting the jaw further (jaw angle implants perhaps) to achieve a more masculine look. There is a bit of asymmetry and the angle of the back of the jaw is more of a 45 degree as opposed to the more masculine 90 degree like angle. It seems that at this point, a sliding genioplasty may not be appropriate without removing the chin implant. I have considered fillers as a temporary ‘trial’ in the short term as a plastic surgeon locally is willing to provide Voluma for free to see if it fits his practice. Any thoughts or observations or anything else that may be beneficial given my facial structure is greatly appreciated.
A: Based on the current position of your chin and the rest of your facial structure, I would have reservations about any type of jaw angle implant augmentation. While you may not like your jaw angle shape now, any change in it would likely make it out of proportion to your chin, particularly if they were changed to a stronger 90 degree shape. That point could be proven, right or wrong, by having some computer imaging done to see how it looks to you. I think that of you do not add some further chin projection (vertical and horizontal) then the back of the jaw will look too ‘heavy’. I don’t think the chin needs to be moved much, maybe 5mm forward and 3mm down, but your chin is too short now to support much jaw angle augmentation.
It is not true that you need to remove a chin implant to do a sliding genioplasty. The osteotomy cut is done right across the top of the implant and the implant is moved forward with the bone as it comes forward and/or down. I have done that exact sliding genioplasty technique numerous times.
You certainly have nothing to lose by having injectable fillers done for jaw angle augmentation. But be aware that they do not produce the exact same effect as to what an implant does at the bone level. So it is not exactly a 1:1 comparative effect. There is probably as much to learn from computer imaging as there is from the filler treatment.
Dr. Barry Eppley
Q: Dr. Eppley, I had an hydroxyapatite chin augmentation several years ago. The hydroxyapatite was semi-solid or loose when implanted- mixed I believe with some fluids, but it was not cut from a block. It was implanted intraorally. Besides not doing much from my chin, it appears that the chin tissues are more loose now and hanging somewhat. I would like to see if we could perhaps fix this problem as much as possible. The tissue also appears more red in color that the rest of my face after surgery. I have attached some pictures of my face for you. I did take them myself from short distance so they do appear a tiny bit distorted, but they give you a good look at the chin and jaw angles in particular. In terms of enhancement to my jaw, I am not necessarily looking for a massively dramatic distal increase in size- just a moderate one to give a sharper look to the lower part of my face and to help with structure as I age.
A: Thank you for sending your pictures. I can’t say that I see any significant soft tissue detachment of looseness per se but the chin is horizontally short. It may feel somewhat looser as the hydroxyapatite granules are not structurally supportive. The hydroxapatite paste put in the chin usually have very little push to it so its augmentative effect is very minimal and often can be very irregular. I am not sure why the chin button area is slightly red as hydroxyapatite is usually very biocompatible. Certainly the hydroxyapatite granules can be removed and other forms of chin augmentation done. A more stouter form of chin augmentation will do a better job of picking up the loose chin tissues as well as providing more of an augmentative effect. At the same time, jaw angle augmentation focusing primarily on vertical length can be done as part of an overall jaw enhancement strategy.
Dr. Barry Eppley
Q: Dr. Eppley, I am looking for extreme jaw angle augmentation. I recently came across a paper that described a technique for mandibular angle augmentation, where segmental distraction osteogenesis and rib cartilage transplants were used to achieve the desired effect. What I found notable was that the degree of vertical augmentation and the extent to which the jaw became “square” was extreme, beyond what I have traditionally seen achieved with implants. For reference, I have included the before/after pictures from the paper below.
My questions are:
1. Do you (or would you) ever perform distraction osteogenesis to vertically lengthen the jaw, without affecting the bite?
2. Assuming you do not perform this type of surgery, would custom implants be able to achieve the same effect to the same degree?
A: That is an extreme approach to jaw angle implant augmentation for which there is a much simpler technique to get to the same place, custom jaw angle implants. I have done numerous jaw angle implants that drop the angles down as much a 25 to 30mms. I see no reason to ever do a distraction technique to achieve that kind of jaw angle result. What that paper is not showing you is the long-term result of that technique of which I will wager that much of the jaw angle lengthening either relapses or resorbs….not to mention the notching that undoubtable develops between the anterior edge of the distracted bone segment to the normal mandible in front of it. The x-ray shown does not show bony consolidation across the distraction site…probably because it does not occur in an adult. Such a result demonstrates that it can be technically done but that does not always mean it is a good thing to do.
Dr. Barry Eppley
Q: Dr. Eppley, I was wondering if you performed jaw augmentation using bone grafts.What do you think about using bone grafts to increase the mandibular angle? Would you recommend it? And if you prefer other materials, why is that? I was browsing the web for some before and after photos of jaw augmentation using bone grafts, but to no avail. If you perform this procedure, and have done so in the past, would it be possible to see some of your work? Thank you!
A: There is a good reason why you can not find jaw angle augmentation using bone grafts…it is not done. It would be a very poor procedure for cosmetic jawline augmentation for the following reasons. First, onlay bone grafts to the face undergo partial or complete resorption. For the purposes of volume augmentation, much of the grafts would likely be lost or they would lose shape. Secondly, the amount of bone graft material that could be obtained and its thickness is very limited. Even using skull, hip or rib bones, it would be difficult to get enough material to adequately do both sides. This is not to mention the pain, discomfort and scars that would result from their harvest. Thirdly, most jaw angle augmentations require vertical lengthening which would mean placing part of the bone graft out into space. This would completely resorb.
For these three major reasons, and a few minor ones that I didn’t mention, synthetic implants are far superior to bone grafts for jaw angle augmentation.
Dr. Barry Eppley