Your Questions
Your Questions
Q: Dr. Eppley, I am interested in jawline surgery. The kind of strong jaw and face I’d like to have is like his model picture that I have attached which shows how her jawline drops and she has very pronounced and positive cheeks which I really like. I want something extremely dramatic, my jawline isn’t anything like the model I showed above. I’m cute, but my face is just so narrow that it takes away from the potential attractiveness that I could have. The debate for me is either a sliding genioplasty and two hardcore flared jaw angle implants OR a custom implant for everything. I hate the side profile view right now, as my nose and philtrum are overprojected and everything else is just weirdly shaped due to my terrible genetic inheritance.
A: Thank you for sending your pictures and providing a detailed description of your jawline surgery goals. While the debate is between a total custom jawline implant or a combined sliding genioplasty with two separate jaw angle implants, for a female and your goals I would choose the latter. The reason is that a total custom jawline implant will make the whole jawline wider from front to back, regardless of the dimensional changes in the profile view of the chin and jaw angles. I don’t think that works well for many female faces. What you want to achieve in the front view is a chin that ends up somewhat more narrow, or at least no wider, as it comes forward, a central jawline that dips in on the way back to the jaw angles and posterior jaw angles that flare out. A sliding genioplasty as it comes forward does make the chin a bit more narrow and it also allows the central jawline to remain narrow. (rather than bow out like a custom jawline implant may create) Your jaw angle dimensional needs is a combination of vertical lengthening and horizontal width for which I already have a variety of jaw angle implant styles to meet those needs.
In the side view you probably needs an 8 to 10mm chin advancement. the jaw angles need a 7mm vertical drop down and a 5 to 7mm width increase.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin implant revision. I had the chin implant placed three years ago. It’s not a huge issue for me, but I think it should stick out a little more to be more proportionate with my lips and nose. Also, from the front I feel like it looks kind of square. Ideally, a little more narrow in the front if that’s possible? As far as the jaw implants, I just want to have definition. I definitely don’t want to look masculine. I just want my face not to melt into my next like it does now.
A: Thank you for sending your pictures. Your existing chin implant is still abut horizontally short, sits vertically high on the chin and is most definitely very square. Your chin implant revision should provide more horizontal projection (about 3 to 4mm), be positioned a little lower and be of a style that provides a more tapered chin look from the front view. It appears that your initial chin implant was placed using an intraoral approach. Your chin implant revision can be done in a similar fashion.
Your jaw angles are high and some vertical lengthening of the jaw angles with just a bit more width would complete your jawline makeover.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about jaw angle implants. I recently saw a question on your blog regarding the inevitability of massteric pterygoid sling disruption when there is vertical lengthening of the jaw angle and was wondering if you could elaborate a bit further on the aesthetic impact of this disruption (specifically, the masseter muscle “roll up” that can occur). Does this mean when the jaw is in a normal position, the bulge of the masseter is going to visibly rest higher than the very bottom of the jaw angle? With lengthening of 10-12 mm, is this effect very significant? I was hoping you may have some sort of visual representation of this effect so that it can be more clearly understood – it seems to be a potential negative drawback of too much vertical lengthening.
A: By definition any vertical jaw angle implant lengthening causes some disruption of the masseteric-pterygoid muscle union along the bottom edge of the jawline over the mandibular ramus area. This is inevitable and a consequence of the procedure. But this does not mean that it is always an aesthetic problem. I have done many vertical lengthening jaw angle implants and custom jawline implants (some as long as 25mms), I would say it was only a bothersome aesthetic consequence in less than 10% of the patients.
Disruption of the masseteric pterygoid sling can cause two aesthetic (no functional) problems. When biting down, the bulge of the massteric muscle can be seen to be higher than the actual skeletal/implant jaw angle location. Or they can be persistent fullness above the jaw angle that prevents a well defined jaw angle definition (or flare of the jaw angle) to be seen. There is no way to predict beforehand what type of vertical lengthening jaw angle implant patient this aesthetic sequelae may be seen in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am researching jaw angle implants and am seriously getting ready to choose a doctor. I consider you to be one of the top few in the nation, and have read your blog on how you’ve never experienced a tear with the masseter sling with jaw angle implants. However, is there still some roll up?
Another well respected doctor has told to me that no matter what there will be a bit of roll up, but did not clarify whether or not that implied no tearing.
A: To clarify the issue of the masseter muscle sling and its potential disruption, you first have to differentiate whether you are talking about width only jaw angle implants or vertical lengthening jaw angle implants. With width only jaw angle implants, it is not necessary to strip the tissues off of the lower border of the mandible. Thus there is little to no risk of any masseteric muscle sling disruption/roll up/retraction issues. With vertical lengthening jaw angle implants or total custom jaw angle implants, that is a completely different issue. By definition it is necessary to elevate the sling attachments off of the border of the mandible and the massteric pterygoid sling is disrupted. This is unavoidable. Whether there will be some muscle rollup depends on how much vertical jaw angle lengthening is created by the implant. If it is 5 to 7mms, for example, then the rollup will really be minimal. But if the vertical lengthening is 15 to 20mms, then it will be more significant. (more visibly noticeable) It is important to remember that the masseter muscle can not lengthen, that is a physical impossibility. So the longer the jaw angle is lengthened, the more the original position or even roll up of the muscle may be seen when biting down.
A complete tear or retraction of the masster muscle is a slightly different situation. For this to occur the entire attachments of the masseter muscle must be detached from the angle point forward to the mid-body of the mandible as well as high up onto the lateral ramus. The angle point attachments are quite significant and not easily dissected off of the bone. With aggressive degloving of the posterior and inferior mandibular borders (and I might add this is almost always done in sagittal split ramus osteotomies in orthognathic surgery) the risk of a more substantial masseter muscle retraction may be seen where the lower end of the muscle is seen up almost at the level of the earlobe when biting down.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle implants and cheek implants. I’m 31 years old and I’ve always felt my cheeks and jawline have been a bit “soft” and chubby despite me being rather skinny, so I was hoping you could give me your opinion. I’ve attached a couple images to the post but I’ve also uploaded a file here which includes multiple angles of my face: I wanted to discuss whether surgery might be appropriate on the following areas, given I’m not at all overweight and I don’t think I could address them via weight loss:
1) You can see there is some fat under my chin towards the back of my neck in the first picture when the camera is tilted upwards (I’m 6’1″ tall so it’s fairly visible in everyday life).
2) You can see from the side views that my jawline is quite “soft” and not well defined in general, particularly towards the back.
3) What I assume is the jowl area (labelled in red on one of the images) also seems quite “chubby” and both hangs down below my jawline and makes my lower face wider and less defined than it would otherwise be. There’s also a pre-jowl “hole” in my jawline in the 3/4 view that may or may not be connected with this.
4) My cheek area as a whole just seems quite flat and undefined when seen from the front. There doesn’t seem to be much shape there, it’s kinda just a large empty space.
I’ve had a chin implant in the past (Implantech Anatomical Chin sized large) and I’m generally content with the new position of my chin, but I was told I had an underdeveloped jaw and I assume that is contributing to these issues. However, as the surgery to fix that issue is such a major undertaking I was hoping it would be possible to address these issues via other methods.
I’m curious as to whether these issues are caused by excess fat or by skeletal deficiency? Would liposuction be a good idea? Are cheek implants a possibility to give my cheeks a bit more structure?
I had cheek implants placed roughly 18 months ago, but I had them removed again 6 months ago as I felt they made my face too wide (and a little feminine), particularly when I was smiling. However, we never really discussed the different areas of the cheek that could be enhanced via an implant before the surgery, so I’m unsure if I was unsuitable for implants in general or if the type of implant was simply poorly chosen.
Thanks for your time and apologies for the long email!
A: Thank you for your inquiry and sending your pictures. For our jawline, I think the fundamental problem is that of skeletal deficiency. By your own admission you had a naturally shorter and underdeveloped jawline that ideally should be treated by orthognathic surgery. But, understandably, you do not want to purse that amount of effort. The chin implant has now provided adequate anterior jawline projection but the rest of the jawline behind it remains deficient and actually now has become more apparent with the chin being corrected. Your jaw angles are high and deficient. This creates a relative soft tissue excess/looseness. While liposuction can be done around the jaw angles and along the jawline, it is not really going to reshape these areas. This is an issue of volume deficiency particularly at the jaw angles. Either preformed or custom jaw angle implants are what you really need to complete the total jawline augmentation effect.
Since you have had cheek implants that were not successful, any reconsideration of them should be done more thoughtfully. I would need to see before and after pictures of your initial cheek implant results and to know exactly what style and size of cheek implants that were used. It is certainly true that a cheek implant is not just a cheek implant. There are different styles of cheek implants and, in my experience, most of the available cheek implant styles are not really made for men. (just like most chin implants do not really work well for most women)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a general question regarding jaw angle implants. I’m currently trying to decide whether to choose silicone or medpor material for jaw angle implants augmentation. I’m trying to create sharp, square, chiseled angularity more than just adding width. I’m getting differing opinions whether silicone is able to do this as effectively as Medpor. I’d really like to go with silicone (particularly a custom silicone implant) due to ease of removal and no tissue ingrowth, but I’m worried the result would be less angular and more soft, such as in the photo I’ve attached (notice how it’s more of a U shape than a sharp V). I’ve read some claims that because Medpor is a harder, firmer material, it creates much better angularity for those seeking a sharper jawline. Basically my question is, if I were to opt for a custom silicone jaw implant, would it able to create just as sharp jawline edges as Medpor material would, or will silicone always looks a little softer?
A: The answer to your question about jaw angle implants is two-fold. First, regardless of implant shape, not every patient has a good chance of developing a sharp angular jawline. The only patients who will do so are those with thinner lean faces with little fat. Men that have fuller and rounder faces with more fat will fail to develop much definition. (as illustrated in the example you have shown) Thus one’s own tissues must be taken into consideration. Second, your selection of a silicone material for jaw angle implants would be best in my experience for the reasons you have mentioned. But the only assured way to get the most angular result is to have the implants custom made. Otherwise you take your chances with performed jaw angle shapes and sizes. As an aside the slightly firmer feel of Medpor does not give it increased angularity. It is the implant’s shape that determines the external change not the implant’s material composition.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I met with a plastic surgery this week for a consultation and asked about the posterior jaw implants. He said no one really does them any more because the implants are known to slip and move a lot. What do you do different to combat this complication? Is this a frequent problem you have dealt with? Thanks.
A: I am afraid that your surgeon is misinformed and not up to date on the most contemporary techniques and use of jaw angle implants. Not only have the styles of jaw angle implants changed but it is now routinue to secure them into place with a single small microscrew. This obviates the entire problem of jaw angle implant slippage after surgery and does a much better job of maintaining intraoperative positioning. There can still be issues with malposition due to intraoperative placement like any other bilateral implant procedure but secure fixation to the bone is the key to obviating the potential movements of jaw angle implants in the submasseteric pocket location.
Along with the understanding that fixation is needed is the development and use of new styles and sizes for jaw angle implants. Vertically lengthening has been an inability to be achieved with older style jaw angle implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline reconstruction.I had upper and lower jaw surgery in 2012 where I was referred by my orthodontist and convinced that I needed it. However, they ruined my face and my bite has subsequently shifted. I would like a sharp jawline. Is it possible to get implants? Now, I cannot close my mouth properly and I have a weak chin.
A: While I do not know what you looked like previously, I can see now that you have a very steep mandibular plane (high jaw angles) and a recessed chin. From a jaw angle standpoint, vertical lengthening jaw angle implants are needed to drop the angle down and provide a more square angle shape. (not really square but closer to 110 degrees) Given that you have had prior jaw surgery (and I assume a sagittal split mandibular osteotomy, SSRO), your jaw angles are likely asymmetric and scarred. Custom jaw angle implants would be the ideal method for these unique jaw angle shapes.
For the chin the options would be either a sliding genioplasty or an implant as part of a total jawline implant which includes the jaw angles. Initially I would favor a sliding genioplasty because the vertical height of your chin needs to be reduced. But a custom implant may be designed this way also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jawline enhancement surgery doing a sliding genioplasty and jaw angle implants. Can the chin surgery be done at the same time as adding jaw angle implants? Would these custom implants be of a material that would be able to last a lifetime? I’m only 25 years old and have already gone through so much with my jaw and teeth that I wouldn’t want to go through with another surgery, but I am very unhappy with the way my face looks currently. I think that a sliding genioplasty with the jaw angle implants would be ideal because I agree that my chin looks rather long and I would rather adjust/fix it than add a chin implant. I know that this isn’t a consultation but what would be approximate cost be for these operations…10-12k or over 15k? I am currently covered under Tri-care but I know that these would be considered cosmetic and probably nothing would be covered with insurance.
A: In answer to your jawline enhancement surgery questions,
1) A sliding genioplasty and jaw angle implants can and should be done at the same time.
2) All facial implants are made of non-biodegradable silicone material which will last much longer than you and I will.
3) I thin the best approach in you would be a sliding genioplasty and vertical lengthening jaw angle implants. The most ideal approach for the implants is to have them custom made because you probably have some degree of asymmetry between your jaw angles given your prior surgery. But in the interest of cost, semi-custom vertical lengthening jaw angle implants can be used.
4) I will have my assistant pass along the exact cost of the surgery to you tomorrow.
5) Unfortunately your assumption is correct in that this would not be considered a medically necessity and would be viewed by TriCare as an elective cosmetic procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper and lower jaw surgery in 2011 where I was referred by my orthodontist and convinced that I needed it. However, they ruined my face and my bite has subsequently shifted. I would like a sharp jawline. Is it possible to get jaw angle implants? Now, I cannot close my mouth properly and I have a weak chin.
A: While I do not know what you looked like previously, I can see now that you have a very steep mandibular plane (high jaw angles) and a recessed chin. From a jaw angle standpoint, vertical lengthening jaw angle implants are needed to drop the angle down and provide a more square angle shape. (not really square but closer to 110 degrees) Given that you have had prior jaw surgery (and I assume a sagittal split mandibular osteotomy, SSRO), your jaw angles are likely asymmetric and scarred. Custom jaw angle implants would be the ideal method for these unique jaw angle shapes.
For the chin the options would be either a sliding genioplasty or an implant as part of a total jawline implant which includes the jaw angles. Initially I would favor a sliding genioplasty because the vertical height of your chin needs to be reduced. But a custom implant may be designed this way also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting jaw angle implants that are of a standard vertical lengthening size that you have designed. The look that I am trying to achieve is a jaw that isn’t “high up”. One that is not quite lined up with my chin but low enough. So I’m just concerned that this will leave me with just a “slight” change and still leaving me with a high jaw line. From your experience and knowledge what is your expectation? I just payed for everything and set for our consultation, I apologize for the questions and concerns, but this is so important to me and Im spending my savings. So all I want to know is, what to expect. Can you not give me some assurances as to the results?
A: The reason I am being nebulous with the answer to your question is two-fold. First it is an accurate statement that no one can predict what the final results will truly look like. Will it be better than what you have now…absolutely yes. Will it meet your expectations….unknown. This is no different that a woman getting 350cc breast implants and asking will it meet her expectations. It is certainly going to be better but whether they are big enough or have the right shape can be hard to answer with absolute certainly. Secondly, the very question you keep repeatedly posing is exactly the reason why your surgery, and any young male who is getting facial bone augmentation, makes me nervous. As I have said before, you are aiming and probably expecting a result that is only going to be achieved by custom made jaw angle implants. But because that it not a viable financial option for you, you are hoping that any non-custom approach will produce satisfactory and fairly assured results. The importance of that to you is further emphasized by your statement that you are spending your savings for the surgery. Patients who put themselves in this financial position, particularly young male patients, often end up with unsatisfactory outcomes.
I would like to emphasize that this is not the type of assurance I can give you. As I have said previously the only way you should have this type of jaw angle implant surgery is by the following guidelines:
1) You view an acceptable result as one that provides any improvement at all to your existing high jaw angles. I can provide no assurance that an 11mm vertical length will be ‘low enough’.
2) If you are seeking a specific target length or certain jaw look, as shown by model or other celerity pictures, and that is the only result that will make you happy…then you should not have the surgery. This is what custom jaw implants are used to create.
3) An understanding that there is a relatively high incidence of jaw angle implant asymmetry when using non-custom jaw angle implants that provide vertical lengthening. When half the implant needs to be positioned off the bone the difficulty in getting symmetry between the two facial sides escalates considerably over any other type of facial implant which is positioned entirely on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw angle implants placed earlier this year and they are asymmetric. I can tell the left implant is way forward of where it should be but I think the right implant is a little forward of where it should be as well. With a revisional surgeryI am actually thinking about going up to the large implant as the medium doesn’t really add that much. Whatever is done, the implant MUST be placed correctly, that I know now. I had no idea jaw implants were so difficult to place correctly. I did ask my Doctor about the placement and he said it’s tough to place them further back because the muscles and tendons tend to push them forward. And he said that it’s not wise to attach the silicone implants with a screw because they are soft and can tear if there’s too much pressure from the muscles. I don’t know if he just made all that up or what to believe now. Do you use implants made of different material if you are going to attach them with a screw?
A:In all due respect to your surgeon, he/she is inaccurate on both assertions about jaw angle implants. To properly position jaw angle implants, muscle and tendons must be elevated to make the pocket. Not releasing these attachments will result in the implant being positioned too far forward. Secondly I screw in every jaw angle implant and 95% of what I put in is silicone. Screws will not tear or disrupt the implant. Without securing them in with a screw the risk is high that they will become displaced or moved from the position/pocket that is made for them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facelift and jaw angle implants. Does it make a difference if they are done together or separately? If they need to be done separately which one should be done first? I have already scheduled my facelift but my gut feeling says that the jaw angle implants should be initially done first. My questions are:
1. Since I should have the implants first…how long after should I schedule my facelift?
2. Do you do jaw angle implants and facelift at the same time? (If I decided to have the facelift with the implants).
3. Would submitting pictures help decide which way to go/
Thanks for your help!
A: While jaw angle implants and a facelift can be done at the same time, I think it is better to stage them doing the jaw angle implants first followed by the facelift three months later. Jaw angle implants cause a fair amount of swelling in front of the ear and jaw angle area. That swelling would seem counterproductive to the pull of a facelift and would work against what the facelift is trying to accomplish. You do not want to stretch out the very skin and tissues that have just been pulled up. (if the facelift is done before and at the same time as jaw angle implants) While I think the two procedures are complementary (both help create a much better jawline), they just should not be done together and the sequence of the staging (implants before lift) is important.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering Jaw angle implants and have a few questions for you. I previously had upper jaw surgery, orbital rim and chin implants done. I feel that my jaw needs augmentation to fit in with the rest of my face, I am struggling to find a surgeon with great knowledge in jaw angle implants and am considering traveling abroad for surgery. If I were to fly to you for surgery how long would I have to stay in the USA before returning home? Also with Jaw implants I hear talking can be a struggle after surgery, how long realistically can I expect this to last? In so far as jaw angle implants type I cannot decide whether I would benefit best from lateral only or both lateral and vertical lengthening? Also the degree of augmentation (small/medium/large). I have attached photos, please can you advise. I am also interested in having the plates from my jaw surgery removed, would this be possible alongside jaw implant surgery?
A: Most patients who come from afar for jaw angle implants surgery return home within a few days after surgery. While patients will experience some difficulty with chewing in the first few weeks after surgery I am not aware that patients have any signficant talking problems. You did not really provide enough pictures to make a full analysis of your face as the all important front view is missing. But as best as I can tell from the pictures provided, medium size lateral width only jaw implants would be my initial impression for your facial needs. While plates and screws from prior surgery can be removed during jaw angle implant surgery I would need to see x-rays of their locations to properly find them. As long as not too much bone has overgrown then they can be removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had jaw angle implants and the implants used were a medium sized lateral jaw angle implants. I can tell the implant does what it is supposed to do and looks good, but I’m afraid the Doctor placed the implant forward of where it should be. I can send you photos. The problem is that this is the 2nd time I’ve done this procedure with this Doctor. Last year we used a posterior angle implant and the result was quite bad. I thought it was because we used the wrong style of implant and should have gone with the lateral implant. However, I now realize that it was because that implant was also not placed correctly. I can’t imagine that a Doctor would intentionally misplace an implant, or that the doctor wouldn’t know where to correctly place the implant. Either way I am not comfortable seeing this Doctor anymore. I found your website and see that you are an expert on jaw augmentation. I am able to travel to Indiana. Are you able to fix my situation by simply going in and creating a new pocket for the implant to correctly place it, or would you have to use a new implant?
A: Thank you for your inquiry and I am sorry to hear of your lack of ideal results on your jaw angle implant surgeries. I do not believe your doctor intentionally misplaced the implants but jaw angle implants are the hardest facial implant to get positioned properly and in a symmetrical fashion. Releasing the tendinous muscular attachments can be difficult and is the key to proper jaw angle implant placement in most cases. Even with proper pocket development and implant placement if they are not secured with screws malposition is highly possible. Since there is so little different between Implantech’s posterior and lateral jaw angle implant styles, you are undoubtably correct in that implant positioning is the issue not the implant style. (as you have discovered after the second surgery)
If the jaw angle implants are providing the proper width increase in the jaw angles and are malpositioned anteriorly then repositioning and screw fixation would be the corrective approach. I obviously have no way of knowing where your jaw angle implants are and would prefer not to presume or guess where they may be. It would be ideal if we knew exactly where they were on the bone and this would best be determined by a 3D CT scan. That would provide unequivocal knowledge as to where they are and how far off from the ideal position on the jaw angles they may or may not be.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, There is one other question that just occurred to me to ask you regarding jaw angle implants. I have noticed that when I clench my molars (I.e., bite down), my jaw looks wider and better-proportioned, which I’m assuming is due to having well-developed masseter muscles. Having said that, if someone’s jaw looks significantly wider when they clench their teeth, do you take this into consideration when designing a custom wraparound implant for them? Should the implant add only minimal width so that the patient’s jaw (after having the implant placed) doesn’t look too wide when they clench their teeth?
A: This is a good question but the simple answer is no, the prominence of one’s masseter muscles are not taken into consideration when selecting or designng jaw angle implants. The amount of time one spends clenching their teeth together or biting done is miniscule compared to the relaxed facial position. It is sort of like selecting clothes or an outfit taking into consideration what does one look like when they are flexing their chest or biceps. (although clearly some people do take that into account) You care much more about what one looks like naturally and not in a muscular contraction state.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about the jaw angle implants that worries me, I consulted a few Maxillofacial surgeons in my country. Some of them said to me that implants under the masseters muscles (for aesthetic reasons, not deformity corrections) is a bad idea, one of them even called jaw implants malpractice. The main argument is that due do the fact the those are the strongest muscles in the body and are constantly active (and mine are even hypertrophied) and will apply constant pressure over the implants, sooner or later it will lead to complications, that the main of them is bone erosion which will lead to relapse at the the best or more severe bone loss at worse.
I’v also been told:
– The procedure is quite aggressive and the masseteric muscles never recover completely from it.
– The procedure will cause mouth closing/ opening problems and chewing problems.
– The scar tissue that will created from the procedure will add 5 mm~ of width to both sides of my face, which will lead to an unaesthetic result, even if the implants will designed for vertical length only.
– The implants will cause thinning of the masseters over time, which will cause further health complications (I don’t remember specifically).
I would appreciate your reply to those concerns. Is the procedure really that dangerous?
A: The simple answer to almost everyone of your jaw angle implants concerns is that none of them are true or are based in any biologic or clinical reality. While it is true that jaw angle implants are placed under the masseter muscles, this does not lead to chewing or muscular dysfunction, underlying bone erosion, or aesthetically undesireable scar tissue formation. The only negative masseter muscle issue that I have ever seen, and it is an aesthetic one is that the pterygomasseteric sling can be disrupted if one is not very careful in their placement. This can lead to bulging above the jaw angle when biting down as opposed to the bulge being over the jaw angle point normally. Other than this potential issue I have found having placed, modified and removed many jaw angle implants that they are as safe and effective as any other type of facial implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 year old female and am interested in jaw angle implants. I have high jaw angles and my jawline looks deficient in the back. I’m interested but I would like to learn more about your experience with this specific procedure. How many cases did you complete that are similar to mine? And if there have been some revisions needed, can you share those stories as well? I understand that jaw angle implants have a high revision rate, and that it takes someone with a lot of experience. Anything you can share on this topic would really help me make a decision.
A: I have performed jaw angle implants for 20 years but the greatest number have been in the past ten years. The incidence between men and women historically is about 20:1 indicating not surprisingly that this is a male dominated procedure. Few women get them although that is slowly changing as more women become aware of their benefits and the desire for a more pronounced jawline has become more desired. As in men, the most common indication for jaw angle implants is in the high jaw angle where vertical lengthening is really needed. This has posed a vexing problem since all current styles of silicone jaw angle implants really only provide width (horizontal increase) and not much if any vertical elongation. This has led me to develop my own style of jaw angle implants that provide specific amounts of vertical lengthening and widths. Such jaw angle implant styles will be available later this year through the Implantech company and will be known as Vertical Jaw Angle Implants.
The revision rate in jaw angle implants has been historically high for a variety of reasons including inadequate/incorrectly chosen implant styles, asymmetry of surgical placement, natural jaw angle bony asymmetry, lack of screw fixation use (particularly in vertical jaw angle implants), lack of most plastic and oral surgeons experience in placing them and patient expectations of what they can achieve in jawline enhancement. These revision rates can be lowered down to that of other facial implant rates (10%t to 15%) with preoperative computer imaging, proper implant style selection, use of screw fixation and a surgeon who is very experienced in placing them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle implants for jawline enhancement. I already had a chin implant placed nine years ago but the lack of jawline definition is making my face look really long. Laterally you can see small bumps of saggy tissue along the weak jawline which has become more visible as I get older or when I lose weight.
A: A weak or high jaw angle (steep mandibular plane) can become magnified with chin augmentation. This is particularly evident when the amount of chin augmentation is considerable, indicating an overall small jaw in both the horizontal and vertical dimensions. This indicates that you need vertical lengthening jaw angle implants rather than width only style implants. With vertical lengthening jaw angle implants the loose tissue which is now in the neck (‘saggy tissue along the weak jawline’) will became redraped over the new jaw angles that have been created. This will smooth out the jawline and make the back match the front for a better overall jawline effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My question has to do with a certain actor. Is the difference in his jaw from the first picture to the 2nd picture from implants and is this outcome possible through mandibular jaw implants.
A: I can not tell you with any certainty as to whether this male actor had jaw angle implant surgery or not. Al I can do is speculate based on my extensive experience with jawline enhancement and numerous types of chin, jaw angle and jawline implants to create an augmentative effect.
I believe that he has NOT had jaw angle implant surgery. What you are witnessing between the two pictures of this actor is the effect of masseteric muscle bulging. In the ‘before’ picture his jaws are relaxed but in the ‘after’ picture he is clenching his jaws which causes his naturally larger masseter muscles (and thin face) to bulge out. This creates the impression that he has had jaw angle implants when he has not.
Such an effect can be created by jaw angle implants provided they are placed in the right kind of face (thin with little fat) and that the implants have the right shape and thickness. Such implants would have to be custom made since no standard preformed jaw angle implants have such an exaggerated shape.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a medium sized Implantech Terino Extended Anatomical implant placed about a year ago. I am interested in getting jaw angle implants and was wondering what style you think would best meet my needs. I like the flared out look of the Implantech Lateral Mandibular Angle implants, however, it also appears that I could use some vertical drop down given by the Posterior Mandibular Angle implants. It looks like the off-the-self posterior implants offered by implantech give 0.36mm of added width. Would this posterior implant give me the flared out look from the frontal view while dropping by jaw angle at the same time?
A; I do not find that any of these types of jaw angle implants would provide a ‘flared out’ look. They can add fullness to the jaw angles but they are not the style of jaw angle implant that can provide an angular flare, particularly if the implant provides any vertical lengthening. A different style of jaw angle implant is needed for that jawline look which is not currently commerically available for off-the-shelf catalog availability.
Dr. Barry Eppley
Indianapolis, indiana
Q: Dr. Eppley, I reviewed the jaw angle implants imaging you provided and have some questions about it. The left side seems slightly asymmetric to the left and the two sides of my face are not perfectly even. Is this the way the surgery will turn out?
A:You are way over reading the jaw angle implants prediction images. I have stated in the past these are approximates so see what direction/dimensional changes someone is looking for. They are not meant to be nor should you interpret fine details in them such as some asymmetries or slight differences in these dimensional changes. These are the variabilities of computer imaging and I also doubt that you are perfectly symmetric either. I should also point out that there are going to be postoperative amounts of jaw angle asymmetry. You will not have a perfectly symmetric result, nobody does. If a patient finds that these fine details are unsettling or is going to critique their postoperative results in the smallest detail, then they are going to be unhappy and have a very high risk of revisional surgery. I make these comments not to be unkind or unfeeling, it is based on a vast experience with male patients and facial surgery. And the goal is not do end up having revisional surgery on any patient.
The reality is that surgery is not an exact science no matter how much thought goes into its preparation and execution. It is an imperfect art practiced on asymmetric features that do not have completely predictable patterns of healing. Therein lies my caution to you. To have a satisfying jaw angle implant augmentation result, one must be prepared to accept some imperfections and realize that a close approximation of one’s goal needs to be good enough.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m really pleased to know a chin implant can be a solution after my chin and jaw angle reduction surgery which has left my face deformed. I’ve sent pics to show how my chin dips in side profile and how the chin area directly below my lower lip protrudes when I smile. I think this is related to mentalis suspension? Really want to get rid of this protrusion, not normal looking.
- Can vertical chin implant get rid of this protrusion under my lower lip?
- Does a “mentalis resuspension” mean, cut along the gum line and stitch it again with a new stiching line in a different place? What does mentalis resuspension mean?
- What is the risk involved in mentalis resuspension? ( Or could it result in a worse bulge/protrusion or some other complications?) Or should I best leave it, if it’s going to risk resulting in a worse protrusion or some other complications.
- The center that did my CT scans seem to think that my jaw angles have been over cut (surgeon took too much bone off?), it was not cut straight and I have indented jaw angles? Does it look as if my jaw angles have been over cut? ( CT scan attached)
- Is it best I get a chin implant and 2 jaw angle implants? Or is it best to get a one piece implant that goes from one side of jaw angle ,across the chin, to the other side of jaw angle?
- Are there any down sides to having screws in your face bones? How many screws will it take to hold the implant(s)in place?
- I read online that a silicone jawline implant does not give good defined bone shape/anatomy, but acrylic PMMA is able to give that defined bone structure, is there truth in this ?
Thank you so much.
A: Thank you for sending your pictures of you and your 3D CT scan after your jawline narrowing or V line jaw reshaping surgery. In answer to your questions:
1) Vertical augmentation of your chin will help with the protrusion as the origin of the problem is the loss of volume from the previous chin reduction.
2) Mentalis resuspension is an intraoral technique where the mentalis muscle is repositioned higher on the bone.
3) The only downside with mentalis muscle resuspension is in how well it works. It has no other downsides and will not make what you have now worse. I do not think, however, that mentalis resuspension is needed for tour chin problem and implant augmentation alone is a better approach.
4) Your jaw angles do look over cut with a severe 45 degree angle to them. That matches with how you loo on the outside of your face. (the indentations over the angles)
5) Unless you want the side of the jawline augmented (which I do not think you do as there is a reason you had the original surgery…a narrower jawline), I would go with a three piece chin and jaw angle implant approach. They need to be custom made and I would design them as a single attached jawline implant (because it will cost you less to do so) but in surgery I will convert it to three pieces.
6) There are no downsides to have small 1.5mm screws in your jawline for fixation of the implants. They are roughly the size of the screws used in eye glasses.
7) A custom jawline implant, made of silicone, creates the best jawline definition and shape over any other material. PMMA would be the worst material to use since you have to shape it during surgery and achieve any symmetry and good shape between the two sides of the jawline would and be virtually impossible. Anyone who would say so otherwise is inexperienced and ill informed and does not have a contemporary understanding of facial implant materials and how to design and place them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle implants to give my jaw a more flared and more square look. I would like my jawline to look like the attached picture. Would that be possible?
A: The ability to achieve a look very similar to your ideal jawline/jaw angles depends on two specific factors. First, you have to have a very thin face over the posterior jawline. Your model picture has virtually no fat which is why the jaw angle is so prominent and it is concave in front of it. You do not have that same anatomy. Your face is fuller so you could never achieve that exact look. Secondly, you have to have the exact implant design to create that degree of jaw angle flare. No off the shelf pair of jaw angle implants does that so a custom design set would be needed.
Based on your attached picture, you would definitely benefit by jaw angle implants. But you would not get that exact ideal result. The very picture you have shown i have seen dozens of times by different male patients who want that exact jawline look. But fir the vast majority of men who seek it, it is not possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, recently I had jaw augmentation and lipectomy. Its uneven and asymmetrical. Obviously nothing is perfect but I expected better. I am interested in your chin augmentations for a better jaw line as well as possible wrap around full custom augmentation. I look forward to speaking with you about these revisions. The liposuction isnt aggressive enough and the implants are sligtly off as I said before. I should have traveled to you first. I am interested in a face time consult with you. As you can see the left jaw angle is different that the right and the liposuction needs to more even and closer around the bone. Hopefully a chin implant and small revisions can accomplish a strong even jawline where the bone line is visible. I don’t know how the doctor I went to has the credentials he has as he is satisfied with this procedure. I wish I came to see you first. I just wanted a defined jawline and facial definition not an asymmetrical nightmare.
A: Thank you for sending your pictures and telling your surgical story. I don’t have the advantage of knowing what you looked like before surgery or exactly what implants were placed. You mentioned that you had ‘jaw augmentation’ but that can mean different things. My assumption was that you had chin and jaw angle implants placed separately (three separate implants)?? If this is so one has to realize that a smooth even jawline that connects the front and the back (chin to jaw angles) is never going to be possible as, even if the implant wings overlap, these are the thinnest sections of the implants. Thus there will always be a ‘dip’ in the middle of the jawline. Only a custom wrap around jawline implant which is made to augment the entire jawline can accomplish that effect. That is the one trade-off for having three separate implants.
However, your description of jaw augmentation may also only be that you had jaw angle implants only. Again they only come so far forward so there is going to be a drop off in the jawline as it approaches the chin. The main complication with jaw angle implants is asymmetry. It is very hard to get perfectly symmetric jaw angles with implants. Symmetric placement is difficult and most people do not have symmetric jaw angles initially. That combination leads to a high rate of jaw angle implant asymmetry.
I would need more information as to exactly what implants you have in place.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting jaw angle implants. My main concern is making this non-obvious to the people who know me. I am from out of town and would be flying in to have the procedure. I was thinking of coming in for two weeks (I..e fly in on the day of or night before the surgery and then stay for 2 weeks to let most of the swelling subside). I was thinking if I possibly grew a beard prior to the surgery and then keep the beard on for a few months, that by the time I shave it off, it wouldn’t really be noticeable to my family and friends. What are your thoughts on this ?
A: That is the most common strategy that men do for any jawline procedure. Be clean shaven for the surgery and let it grow for 2 to 3 weeks and then shave it. That does make for non-obvious surgical change. By three weeks 80% of the swelling has subsided. The resulting 20% residual swelling is not that noticeable as it continues to go down almost completely by six weeks after surgery. I do not think you need to leave the beard on for months as the swelling will have gone down long before that. It is also not necessary to stay here for two weeks. If swelling was not an issue, you could go home within twp days. If swelling is a concern, one week should be sufficient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw angle implants for the asymmetry between the fullness/width at my mandibular angles. I am lookingfor a Oral surgeon/plastic surgeon combo who has experience working in the mandibular area because a few years ago I had a BSSO and after the surgery this asymmetry became more apparent to me. I had synthetic fillers placed on the deficient side a few months ago and they worked well but I don’t know if this is something I am interested in doing for the rest of my life and possibly want a long-term fix. You seem experienced with this type of surgery and therefore I am reaching out.
A: Many times after a BSSO mandibular procedure there will be changes in the shape of the jaw angle area. This is due to either how the proximal and distal segments of the BSSO were put together, bone resorption or both. Jaw angle implants can reshape these areas nicely and the only question is whether they should be custom or off the shelf implants…that would depend on the magnitude of the deformity and how asymmetric the two sides are.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 year-old male who is interested in jaw angle implants. It seems to be hard to find surgeons who do this procedure with any regularity or expertise in it. I’ve met many surgeons during the last three years and none seems to be expert in it. I know the distance could be a problem in case of complications, but I’m financially ready and, if I remember well, we talked a couple of years ago on another website about this procedure. I had a rhinoplasty and chin implant back in 2010 (conform extended anatomical chin implant, size large, Implantech) and I really would to go on with the work on my face having jaw angle implants.Do you work on international patients? And are two weeks there enough to fly back safely? I see my face as very vertical, so I think I would only need width and not add further vertical projection.
A: I would certainly agree based on your pictures that you only need width enhancing jaw angle implants and not vertical lengthening ones. While the surgery does cause some swelling I would see no need to be here any longer than 5 to 7 days at most before flying home. Fortunately any serious complications are very rare (e.g., infection) so being at a great distance is rarely an issue.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 21 year old man and I was looking to have jaw angle implants with you. But first I would like to have your professional opinion if I really should get the implants? And to have better results should the implants be customized? And how much does it cost to have custom jaw angle implants?
A: In looking at the side view pictures that you have provided (which only provides an incomplete and one-dimensional view of the jawline), I see no benefit to jaw angle implants for you. You already have a fairly low mandibular plane angle (linear relationship of the jaw angle to chin line compared to the Frankfort horizontal line) and you would not want to drop it down any further. Whether there is any benefit to width only jaw angle implants requires a frontal view picture to make that assessment.
Jaw angle implants come in two fundamental types, width only and combined vertical and width angle types. The vast majority of patients, male or female, seeking jaw angle augmentation have a high jaw angle or a steep mandibular plane. This requires a vertical lengthening style. Less commonly, the angle position is vertically satisfactory and a more defined shape is needed through width enhancement
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a bimaxillary correction surgery last year. After the surgery I’ve lost my jaw angle.My jaw angle was near 90 degree.I have before-surgery-x-rays and want it back,but I’m worried if that doesn’t look good on me. I heard that you prefer silicone with a 3D custom implant fabrication. Would that be slippery? (compared to medphors) In my case,I only need a verical lengthning (a lot).
A: It is not rare that orthognathic surgery, specifically sagittal split ramus osteotomies, change the shape of the jaw angles. This can be due to an actual change in the jaw angle bone shape with advancement movements, loss of masseter muscle mass or both. It can also occur in short jaws where the jawline and chin move forward but the jaw angle position remains high, thus causing an illusionary change in the jaw angle shape. Regardless of the cause, restoration of the jaw angle can be done using jaw angle implants. You specifically have pointed out the dimensional change needed which is vertical lengthening. Of the available off the shelf preformed jaw angle implants, vertical lengthening styles are available in either silicone or Medpor materials. Either type of vertical lengthening jaw angle implant is secured into position by a screw which is important when half of the implant is placed below the level of the bone. Depending upon asymmetry issues, which may occur after mandibular advancement surgery, a custom implant approach may be preferred to create the most optimal symmetry between the jaw angle sides. If one is concerned about how lower and more prominent jaw angles may look, computer imaging can be done to help with that assessment. I would need to have some pictures of your face to do that computer imaging assessment.
Dr. Barry Eppley
Indianapolis, Indiana
