Q: Dr. Eppley, I had jaw angle implants and they appear to be asymmetric. My gut feeling was that the implants were not placed correctly. I could see quite precisely where each implant was. It is beyond my comprehension how my doctor (or any doctor who does this procedure) could not know how to correctly place the implants. My fear going into the surgery was that the final result might look quite good, but possibly be a little more or little less augmentation than I was wanting and that I would have wished that I had gone with a larger or smaller implant. Many plastic surgeons don’t do jaw implants so when I found one who did I just figured he would have the training and experience to know how to do it. And they did show me some before/after photos of a couple jaw implants they did. One guy was young like me and had an excellent result so I figured I would too.
As far as fixing this, how difficult is it to go in and reposition it correctly and attach it with a screw? I also must say that I am considering going up to a large. I held the medium implant in my hand and it seemed like it would provide a lot of augmentation, but in reality it doesn’t. I was worried the medium could actually be too much, but now I actually think I need a bit more than what the medium gives. When you do the revision jaw angle implants surgery can you just remove my current implant and then put in a large implant (correctly) in one surgery? Or if I stick with the medium can you go in and just reposition it correctly and attach it with a screw?
A: I think you are being a little harsh in your surgeon. Jaw angle implants are hard to do and implant asymmetry is not rare. I have a tremendous experience doing this type of facial implant surgery and it will occasionally happen to me as well despite my best efforts. The overall need for jaw angle implant revision surgery is about 15%. Whether you keep you existing jaw angle implants or go up a size, the effort is the same to reposition it and screw it into place.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in jaw angle implant revision surgery. I just got jaw angle implants with facial liposuction. I’ve always wanted a more defined jawline. So I got the procedure done. My doctor did the type of jaw angle implant that widens. But I wanted the one that lengthens and wides a bit. So already he didn’t do the one I wanted and he went too wide. It’s 4 days after surgery. Is it bad to remove implants and replace with others? Is their risk involved? I’m very unhappy about how he did this.
A: Th first thing to realize is that it is just four days after your jaw angle implant surgery. This is a time period of maximal swelling so it would be impossible to have any idea as to what the final result would be. It generally takes four to six weeks to see the final result. So the final result may or may not be what you want.
But let’s assume for the sake of this discussion that your current jaw angle implants are inadequate. It is very straightforward with no increased risk over the original surgery to replace your jaw angle implants with a new design. Because you have an existing implant pocket, the amount of swelling and recovery would be significantly less than the initial implant surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I wanted to ask you a quick question regarding jaw implants revision. I am a 29 year old male and have had silicone jaw and chin implants placed previously. I am very happy with them, however, as time has gone on I feel like the jaw implants could be slightly larger in width(1-2 mm each side at most). I am perfectly happy with the chin implant. I know you had said this desire for further augmentation is a common occurrence among young men and clearly you were right. I guess my question is a two part question. The first question is if fillers can address the slight augmentation desired, and if so which filler should be used? Any risks associated with this since there is a pocket and an implant already there? The second question is that were you to suggest surgery, would it be a very difficult procedure to remove just the jaw implants and replace them after nearly 3 years? I would of course like to do this as minimally invasive as possible.
Thank you so much for sharing your knowledge and providing this valuable advice.
A: Whle you certainly can have fillers done, I dount they will be very satisfying in the long run. Since you have jaw angle implants in place, it would be important to make sure that the injections avoid violating the implant capsule under the muscle. I don’t think the type of injectable filler used matters , they all will work. The injection technique is more important that want is placed.
For a permanent increase in jaw angle width, you can either replace the implants you have or use a wafer or wedge technique to augment what is in place alreasy. It is much easier that the first jaw angle implant surgery as you have an established pocket to do either. The simplest, and probably the most the most effective to do what you want accomplsih is the wafer method. This is where a wafer of implant material is put behind the existing implants to create the increased thickness. This does not necessitate the need to remove the implants, merely lift them away from the bone to slide the wagfer of extra material.
Dr. Barry Eppley
Q: Dr. Eppley, I am in need of jaw angle implant revision surgery, I had large, off the shelf, silicone jaw implants done two weeks ago. To me (at this stage) they look too big and are asymmetrical. As you can see from the photographs there is a distinct difference to both sides of my face, with one jaw side being lower than the other. i am also concerned that they bulge and “round out” my face from under the ears. also believe they made my face longer and squarer. I want badly to correct this and if this entails customized implants that achieve (or approach) symmetry, I hope you can help.
A: Let me start by first making a general comment about jaw angle implant surgery in men. Just about every patient in the first few weeks or month after surgery thinks that the implants are too big, asymmetrical or both. While they may very well be (I obviously don’t know what you looked like before and what your aesthetic goals were…and the beard adds another visual element which may or may not be helpful in interpretation of the results), what is important to know is that 50% of the final result is seen at 3 weeks, 75% of the result is seen by 6 weeks and it takes a full 3 months to see every detail of the final result in any form of facial skeletal augmentation surgery. So at just two weeks after surgery what you are currently seeing may or may not be a harbinger of the eventual outcome of the procedure.
I say this because I have seen numerous men jump too quickly into jaw angle implant revision surgery…long before the final result was apparent. There is an accomodation phase to the new look and that does not happen for most patients in the swelling phase of the recovery period.
The two most common complications from any facial implant surgery, in particular jaw angle implants, is what you are feeling now…over/undersizing and asymmetry. Given that you are still somewhat swollen it it hard for me to know what look you were trying to achieve and what makes the way it looks now not desired. Did you have computer imaging done before our surgery to get a feel for the look you could achieve in your face? Your description suggests that they are too big (wide) and are of a lateral design…which would account for the rounded lower face look. I suspect these are 11mm wide lateral angle implants. Such dimensions can also make the face look more square and longer (which is what many jaw angle patients want) but this style implant has very rounded edging.
Jaw angle implant asymmetry is a function of placement and how secure the implants are onto the bone. They were placed from inside the mouth but where they secured with screws?
I ask these questions because the solution to your jaw angle implant concerns may already lie within you (modification of existing implants and their positioning) While custom implants can always be made, I would first look at whether what you have can be salvaged to the right amount of jaw angle augmentation and symmetry…consisting of the simplest and most economic approach to jaw angle implant revision surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I had Medpor jaw angle implants placed a year ago, but they did not provide sufficient lateral and vertical augmentation. I have been told that it would not be possible to replace the existing jaw angle implants due to Medpor’s tissue adherence, which is why I am thinking of getting a Medpor square chin implant with longer width to provide that augmentation.
That being said, I would very much prefer to get the Medpor jaw angle implants replaced, but I’m unsure if that’s possible. Do you think its removal would prove too difficult to be worth the risk? If not, could I replace it with another Medpor jaw angle implant at the same time?
A: If the proper jaw angle implant style is not used, the vertical elongation of the jaw angle area that many patients really need will not be achieved. While Medpor facial implants are harder to remove than silicone, it is not true that it is impossible to remove them. I have removed and replaced numerous Medpor chin and jaw angle implants. If you are still focused on using Medpor jaw angle implants then it would need to be the RZ style of either a 7 or 11mm width. Removal and replacement of jaw angle implants is done at the same time as that would be the most convenient and efficient way to do it.
Dr. Barry Eppley
Q: Dr. Eppley, I have some questions about jaw angle implant surgery.
1) If I have a jaw implant surgery, do you custom make the jaw implant for my specific jaw? Is custom making an abnormal activity for jaw augmentation practitioners or something that is done with regularity at most clinics?
2. Which material do you normally use as implant and from which brand? Why do you do this type or these types of implants?
3. What are the best/worst properties with these type of implants?
4. Approx. how many jaw implants have you done in 2012 and 2013 and what are the total number of jaw implants you have done?
5. If you were to say a number of the total people that have underwent jaw implant surgery, how many have come back of the total number and been displeased with the result?
6. What were they not happy about? and what do you do in such an situation?
A: In answer to your questions:
1) I would need to see photos of your face to make an assessment of whether you need standard or custom jaw angle implants. It has been awhile since I have seen your pictures. Regardless, using custom jaw angle implants is done by a very few surgeons in the world.
2) Depending upon what dimensional changes need to be done, the implants could be made from either silicone (widening the jaw angle only) or Medpor if vertical lengthening of the jaw angle is needed.
3) I do dozens of cases of standard and custom jaw angle implants every year.
4) To you on the outside, the different materials of the implants are irrelevant. Your current choices of jaw angle implants is based on what dimensional changes you need so you really don’t have much choice when it comes to vertical lengthening jaw angle implants because only one manufacturer (Medpor) makes them.
5) The revision rate of jaw angle implants is not insignificant and averages around 20%. This is the hardest facial implant to surgically place.
6) Asymmetry is the biggest reason for revision of jaw angle implants. In some cases, the result may be too much or too little for their aesthetic liking.
Dr. Barry Eppley
Q: Dr. Eppley, I have had multiple jaw implants that have left me with an unsatisfactory result. My jaw is naturally asymmetrical so it was hard for the surgeon to match left side to right side I suppose. He tried to fix the asymmetry by shaving down the implants, then another surgery to add implant on the right side which just made it bumpy and stuff. I think I just need to start over with newly designed implants. In addition I also want a reverse sliding genioplasty, my chin sticks out too far and looks unnatural. I can get a 3D print of my skull and a physical 3D exact model from a computer, so that new implants can be made to make my face sides perfectly symmetrical. I have attached a video which described in detail exactly what I don’t like about my jaw result.
A: I have seen your video and your problem is one I have seen many times. I can make the following comments:
1) Jaw angle implant asymmetry is not uncommon and is a result, most of the time, from different placements on the jaw angle rather than some inherent bony asymmetry. Bony asymmetry does not help but it is actually very difficult to get perfect symmetry (alignment of flare) between two jaw angle implants.
2) The problem you have on our left side is that the two implants (chin and jaw angle) do not meet, thus leaving a depression or lack of smoothness between the two. That, again, is reflective of the asymmetrical placement of the jaw angle implant on the left which is further back and higher than the right one. Note that your right side is smooth probably due to the better position of the right jaw angle implant.
3) Correcting jaw angle asymmetry, in my experience, rarely works by just shaving down the implants while they are in place. The implant almost always has to be removed, modified if necessary and then reinserted in a better position. Modifying it while in the patient is treating implant malposition by adjusting the shape or thickness of the implant, potentially worsening the problem or at the least ending up no better for the efforts.
4) You are correct in now assuming that the best approach to the problem is to get a 3D model of your jaw, see exactly where the implants are and make new implants if needed.
5) As for your chin, I do not have the advantage of knowing what you looked like before. But your chin result is not particularly abnormal or unexpected. It may be more projection than you want but many chin implants when placed on a smaller chin will end up with that result. It may look like it is sticking out and the labiomental sulcus will deepen. Medpor chin implants are thicker and more bulky than other materials and this may also be part of the aesthetic problem. You may simply benefit from a smaller projecting chin implant design.
In conclusion, making a completely symmetric 3-piece chin and angle jawline enhancement is not as easy as it looks on a skeletal model and you, unfortunately, are reflective of some of the problems which can occur. But your next step of getting a 3D analysis of what you have and why it looks that way is the only effective way to move forward.
Dr. Barry Eppley
Q: Dr. Eppley, I have been on your website which is quite impressive….I had jaw implants/small chin implant and a little lipo on the neck/jaw area. It’s been 8 weeks exactly and although a major amount of swelling has subsided, it still seems too large and one side is quite noticeably larger than the other…..not symmetrical….my surgeon is a notable surgeon so I have faith in him but just feeling a little down that at 8 weeks I’m still a little looking like a super hero and I’m a relatively small woman with a “small” profile so to speak….also my smile is still effected as my lower lip does not lower to show the same amount of lower teeth….is this all normal…..the swelling, asymmetry and these feelings of despair…..thanks for your advice.
A: All I can say about your present surgical situation is what I have seen in my own practice. If the jaw angle implants are too large at this point in your recovery, particularly for a woman, then they are simply too large for your face/aesthetic desires. If there is jaw angle asymmetry at 8 weeks after surgery, even though some subtle amounts of swelling may still go down, is indicative of asymmetry of the jaw angle implant positions. Jaw angle implants are very difficult to place perfectly symmetric and it is not rare to have a malposition of one which will appear like a ‘lump’ on that side of the jaw angle. Putting these two together would indicate to me that you are headed towards a revision, downsizing the implants and adjusting at least one of their positions. It is not a question of if…but when. Your plastic surgeon will tell you to wait longer because of ‘swelling’ but the final outcome will not change. If the jaw angle implants are silicone then there no harm in waiting as they are easy to remove and replace. If the jaw angle implants are made of Medpor, then sooner is better than later due to tissue ingrowth.
Dr. Barry Eppley
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
Q: Dr. Eppley,I had custom jaw implant surgery a while ago. The sizes are 9mm for each side. I would like to increase the sizes but I’m not sure how large I should go for. I was thinking 12mm for my left side and 14mm for my right. Is this too large?
A: I would not think that jaw angle implant change is too large aesthetically. I would worry more that it may not be big enough. On pure ratios of measurement change that is a 25% increase on the right side and a 45% increase on the left side. From a tissue stand tolerance standpoint, you could double the size of the implants and the tissues would have no problem expanding too them. Your issue is one of desired amount of aesthetic change not what is physically possible.
Dr. Barry Eppley
Q: Dr. Eppley, I got jaw angle implant one year ago and want to get new ones. I have two problems with the ones I have. The first thing is that they did not give me the look that I wanted. They added very little width and did not make the jaw angle any more prominent. The second thing is that one of them has slipped and is starting to come through the incision as it is sore and I can see an edge of it inside my mouth. What do you recommend? I have a picture of me so you can see where I am now.
A: Based on this one picture, I believe your jaw angle goal can be achieved with an off-the-shelf implant as it appears that what you need is more width and jaw angle prominence. That can be done with either a silicone lateral augmentation style or a medpor inferolateral augmentation style (modified) based on your width desires. I know that you said you have jaw angle implants now but I don’t know how much they are adding to where you are at present. Besides one of them slipping (they should always be screwed in) they may not be big enough or placed low enough on the mandibular ramus to have the proper effect. This is both a sizing and placement issue. If you desire a much more prominent jaw angle, I would consider using a medpor RZ angle implant of the 11mm size. That will give you the most prominent jaw angle possible with a preformed jaw angle implant.
Dr. Barry Eppley
Q: Dr. Eppley, I recently had jaw angle implants and it has not turned out to be a good experience. My jaw angles were high and made the back part of my face looked weak and absent. My surgeon initially placed silicone implants but all they did was make my face look more wide and fatter and did nothing to make the jaw angle change I needed. My surgeon acknowledged that these implants were not the right types. I then had a second surgery done using Medpor jaw angle implants. Even though there was a lot of swelling after surgery, I noticed that my left side was very different from the other side. This has become only more apparent as the swelling has gone away. They look and feel completely different between the two sides. My surgeon says he wants to go in and shave down one of the implants but I have lost faith in him at this point. What do you recommend?
A: Sorry to hear of your surgical misfortune. Jaw angle implants are, without question, the most difficult facial implant to do well, both in implant selection and in surgical placement. They are incrementally more difficult than the more commonly used chin and cheek implants. Symmetrical placement, because you have to put in each implant independently and without view of the other one, is challenging. One has to be very attentive to every detail of the implant position and to screw it into place, if possible, to ensure the best symmetry. The most difficult jaw angle implant to place are the Medpor ones because their material surface has a high degree of frictional resistance and they don’t slide in easily. That is the only jaw angle implant, however, that can drop the jaw angle down vertically. Most of the time, these implants have to be trimmed down to fit, removing the long anterior end. I have found it very beneficial to use the implant sizers first to fully develop the pocket and only place the final implant when the sizer slides it easily to the desired location. It would be impossible for me to say what is the best approach with your current jaw angle implant situation. I don’t know what you look like now nor do I know the details of your current implants and what is making them asymmetric. Shaving down the malpositioned implant may work but, more likely, the implant needs to be repositioned.
Dr. Barry Eppley
Q: Dr. Eppley, I had silicone chin, cheek and jaw implants placed.Within a month, the jaw implants and the chin implant had shifted. The right jaw angle implant actually shifted through the incision into my mouth.The doctor repositioned both implants in a revision surgery. I asked him about fixating the implants with screws, but he insisted that a stay suture would hold them. Despite the stay suture, this time the left implant shifted — through the incision and into my mouth. The right implant seemed to be fine. In a third surgery, the doctor repositioned the left implant, with a stay suture again. Lo and behold, I discovered this afternoon that the right jaw angle implant has again shifted through the incision. A tiny sliver of it is poking through sutures which I thought would have dissolved by now, but which have not. I would like to have both implants repositioned and fixed with a screw. Can you do this type of revision?
A: Thank you for sharing your story. I am very familiar with why you have had recurring problems and it is not a mystery as you undoubtably know. Smooth silicone jaw angle implants are easy to put in which is why many surgeons use them. But unless they are positioned properly down at the inferior border of the mandible and secured there by a screw, there is always the risk of extrusion. While many such placed silicone jaw angle implants do not migrate and extrude, it is not rare when it happens. I have seen numerous patients just in the past few years who have had an identical problem. I experienced it myself when I placed my first set of silicone jaw angle implants over ten years ago…and vowed never to go through the endless revisions again which always ended up with recurrent extrusion. There is nothing wrong with silicone jaw angle implants, and placing a screw in them is not easy, but the avoidance of an extrusion risk is well worth it.
Given that you may not have the opportunity to revise your jaw angle implants for months, I would strongly advise getting them out so the open wounds can heal. These openings cause the posterior mandibular vestibule to deepen and make less tissue available for a competent closure over any new implants that are placed which increases the infection risk in replacement surgery. This also allows the incision edges to heal and hold sutures better down the road.
Dr. Barry Eppley