Your Questions

Q: Dr. Eppley, I was browsing through your website looking at facial implants and I realize that you are one of the experts in this field. I have a very small mandible and got my overbite fixed with 3 years of braces. However, afterward I still had a very small mandible. I got a silicone chin implant to fix my small chin. I am mostly satisfied with my chin. But I still have a very thin and weak jaw and I would like to get jaw implants to get width and angles on my mandible in the future. I look forward to hearing from you and discussing with you to determine the best possible process.

A: With a very small mandible, the jaw is usually deficient in more than just the chin area. It is really small from front to back throughout its entire length. The means the jaw angle area will be rotated upward, giving one high jaw angles that have little width. While the chin implant provides greater horizontal projection to the front of the mandible, angle implants are needed to improve balance at its back end. But the jaw angle implants must have a very specific style and dimensions to be effective. With high jaw angles, the implants must provide vertical lengthening as well as some width. Most current styles of jaw angle implants don’t provide these dimensions so you have to very careful to get the correct style to get the desired aesthetic result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I developed an infection after getting with jaw implants. I had them taken out right away. However after the surgery my incision is having a hard time closing and I was able to express some pus from the area about 0.1 cc. The abscess from the previous infection is not back but it appears to be not healing well. I think it might be related to the closure as the mucosal remnant next to the teeth was narrower than 1cm that you try to keep when you make the incision. Or it could be that the original infection caused that mucosa to shrink a little bit.  What do you do in this situation?

Also I was wondering what you find are some of the common reasons for one to get the jaw implants infected.

A: What you have is contracted or inverted mucosal edges which lead to of fluid and food debris trap as it struggles to heal. If this is a chronic problem of months then I would  excise and reclose the wound in layers. If if just weeks or a month old, I would give it more time. Most of these wounds will heal but it is slower when you have a previous underlying implant pocket.

Having done a lot of jaw angle implants with every conceivable implant option, I have learned the following about the risk of infection and how to prevent it.

1. Good wound closure is paramount, a two-layer closure with muscle reapposition over the implant and then a good water-tight mucosal closure. This starts with an incision placed away from the vestibular tissues so you have good tissue on both sides of the wound to close.
2. Medpor implants have a higher infectivity risk than silicone due to its porous material. Pre-soaking, vacuum infiltration and antibiotic irrigation must be done.
3. Avoid using the final implant as the sizer and developer of the pocket. Use the manufacturer’s sizers for this process during surgery. That way you grab and insert the final implant but one time through the mouth, a so-called minimal implant handling technique.
4. Implant stability is really important but most paramount for silicone jaw angle implants. Their smooth surface makes them predisposed to being displaced after wound closure and working their back toward whence they came…getting near the incision and even work its anterior edge through it in some cases. I always use screw fixation with jaw angle implants, most easily done through a percutaneous approacsh using 1.5mm self-tapping screws.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been reading for quite some time on your website and I found a lot of terrific information.  I am looking for what you describe as the “Male Model Look”. Could you please tell by the enclosed photos what procedures you would suggest for my face in order to achieve this look. I have been reading about jaw angle, jaw, implants and cheek implants but would like to know what you suggest for my particular face.  What else would you suggest? I am 38 years old. I have already had my ears pinned one month ago. Could you also do a custom facial imaging so that I have an idea how I will look (more or less). 

A: Thank you for your inquiry. The so called Male Model Look is really about accentuating some or all of the skeletal highlights of the face. These include the brow bones, nose, cheeks, chin and jaw angles/jawline. One has to not have too thick of facial soft tissues to see the effects of the augmentations. When analyzing your face, you have the right amount of soft tissue cover to show these effects well. You are most deficient in the jawline area (chin and jaw angles) and secondarily in the cheeks. For starters, I have just focused on these three areas as you can see in the attached computer imaging. There would be the 'best value' procedures for your face. The only other thought would be some nasal thinning in the tip area. (but I have not done that so you can focus on the more important areas for now)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a long-time reader of your blog and it has been a terrific resource over the years, so thanks for all the great work that you do!

I have a concern about the jaw angle implants I had placed about seven weeks ago. I wanted and thought I was getting Medpor “Angle of the Mandible Implants” with 5mm lateral projection and 10mm inferior projection but ended up with “RZ Mandibular Angle Implants” due to a major misunderstanding with my surgeon. The implants currently in place have a whopping 11mm of lateral projection and negligible drop-down. As you can see from my “after” photo, these implants extend well past my zygomatic arch, resulting in an “hourglass” shape that I don’t care for. My question is, if I swap out the implants I have for the implants I originally wanted, do you think (based on my “before” picture) that I will experience a similar version of the same problem–just on a smaller scale? In other words, do my high arches and thin skin doom me to that hourglass shape no matter what? My aesthetic goals are to 1) make my jawline flush with my arches and 2) achieve the drop-down effect available only with the “Angle of the Mandible Implants.”
Thank you so much for your time and consideration!

A: The current problem with your indwelling implants, besides the fact that they have too much lateral projection, is that they are malpositioned high up on the bone rather than wrapping around the lower border of the mandible. This then gives you closer to 15mms lateral projection because the implant is actually rotated 15 to 20 degrees of how it was intended to be positioned on the bone.

I think you can reach your goal by one of two implant approaches. A Medpor RZ style jaw angle implant is fine if it was the small 3mm lateral projection size. Or the Angle of the Mandible Implant (aka Ramus with inferior ridge) with 5mms lateral projection would also work. Both would need to be trimmed to fit but you need a surprising small amount of lateral projection to stay within your zygomatic arch width.

However, the use of these new implants will still create the same problem if they are not in proper position on the bone. Placing jaw angle implants that drop the angle vertically downward are technically difficult. All of the soft tissue must be released from the inferior border, including the tendinous attachment to the jaw angle, to allow the implant to sit in its intended position. Also, when jaw angle implants are placed at this level they are inherently unstable because they is never a precise implant to bone fit. (the shape of your jaw angle I can guarantee is different than the skull model from which the implants are made) This is why screw fixation is almost always needed to ensure proper implant positioning as half of the implant is not on bone.

The problem you have is one I see when the surgeon may be used to placing silicone jaw angle implants, none of which have designs to drop the jaw angle down. This is a much more simpler procedure which involves just sliding the implant along the bone surface, dropping it into place if you will. (this is why your implants look the way they do now)Placing vertically lengthening jaw angle implants is much more difficult to do and is further complicated by the frictional resistance of the Medpor material, further adding to the difficulty of the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do you feel it is possible to create an aesthetic male face even with my Class 1 hypertelorism? I understand that it can be found to be an attractive feature in women (such as Jackie Kennedy), but I can’t really seem to find any examples of good looking male face with hypertelorism. Do you know of any? Thanks!

A: First degree hypertelorism, as you have been mentioned, can be attractive in females. You have mentioned Jackie Kennedy as an historic example but Uma Thurman would be a more recent illustration. When it comes to men, however, I have never heard it so described and can not think of any example where it is.

The spacing between the eyes can be improved by several facial camouflage strategies. I have not seen a side view of you so I can not say how successful they would be in your case. Building up the bridge of the nose, usually with an implant,  is a classic example of decreasing the distance between the eyes. This is best done in patients that have a low or wide nasal bridge. The higher the nasal bridge, the less the eyes look far apart. In addition, widening the lower face can also help camouflage it. Cheek and jaw angle implants in particular help widen a the lower 2/3 s of the face.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I feel my face is a little weak down around my jawline area. Iwas hoping to have a more masculine jaw with out elongating my face any more… just maybe make it more full. Also as you can see on my photographs, my face is very asymmetrical. My right temple seems sunken in so was researching your page and saw you have a temporal implant, was wondering if I good candidate for the procedure. And last but not least, my nose is also very asymmetrical. If I feel above the nostril I can feel more cartilage on the left side of the nose and my right doesn’t have any. I am open to suggestions please if you can let me know the procedure you believe I will benefit from.

A: From a jawline standpoint, there is a clear chin deficiency but with a slightly long (rotated backwards) chin as well. While an implant can be used and probably not lengthen the chin, the most ideal treatment is an osteoplastic genioplasty where the chin can be brought forward and shortened as well. I have imaged that potential change in the attached profile pictures. In addition, I have also added some small jaw angle implant in the front view to see if widening the posterior jawline is also aesthetically beneficial. 

As for your nose, I can see a slight retraction of the alar rim upward creating nostril asymmetry. That would also account for the differences you feel in the lower alar cartilages in the tip of your nose. This could be improved by the addition of an alar rim/onlay graft to the right side of the tip of the nose.

As for the temple areas, I am having a hard time to seeing the amount of asymmetry between the two sides. This may be a function of the photograph. For temple asymmetry, a small subfascial temporal implant can provide a moderate amount of augmentation to the more depressed side.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have suffered a jaw angle deformity since I had jaw surgery two years ago. There is a big notch along the border of my lower jaw in front of the jaw angles. I think jaw angle implants would make a massive difference. It is something that’s high on my list to do providing I can find someone who will do a good job and providing there isn’t any major risks with my prior surgery. I was thinking fillers as a temporary fix until I can find someone who can perform the surgery as I would much rather have a permanent fix. 

How would you build up the bone? What’s involved in that? 

How does notching come about?  Was that a complication from surgery? Was it something I was born with?

A: Without question, jaw angle implants are the solution to your problem. The only question is what size and shape should they be. Most likely, off-the-shelf inferolateral border jaw angle implants will be satisfactory. Ideally, custom jaw angle implants are the best but that adds some expense to the procedure.

Injectable fillers are fine if you are not planniing to have the surgery anytime in the next six months or so. But if you are then I would not do them so they do not interfere/obscure the surgery.

Notching of the inferior border after sagittal split mandibular osteotomies can occur from a variety of reasons including a non-union, bad osteotomy split, too much rotation of the posterior mandibular segment, inadequate bone fixation, and the shape of one’s natural mandibular ramus anatomy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have asymmetry of my jawline that I want to improve. While I think  both jaw angles need to be be bigger for a better jawline look, they are not the same size now. What is the best way to making them both bigger and more symmetric? I don’t want to get jaw angle implants and then afterwards have bigger jaw angles that may look even more asymmetric. 

A: There are two approaches to both increasing and improving the symmetry of your jawline. Either use two different-sized jaw angle implants or have custom jaw angle implants made. Stock off-the-shelf implants are less expensive but it is a guessing game in terms of the symmetrical improvement. If you can live with less than perfect symmetry then this is the way to go. Even in the patient who has weak but symmettric jaw angles before surgery, it is difficult to end up with perfect symmetry afterwards even using two symmetric  and identically-sized implants. If you want the most ideal symmetry possible, then custom jaw angle implants are needed but they are more expensive. The most common complications from jaw angle implants, ironically, is asymmetry so you can see that having initial asymmetry makes jaw angle implant surgery even more challenging than it normally is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My question is about the after surgery effects from getting jaw angle implants. I am also going to get an osteoplastic genioplasty at the same time for a complete jawline makeover. What level of pain do most patients experience and how long does the recovery and healing process typically take?

A: To answer the recovery question, it all depends on one’s definition of recovery. But if defined in terms of return to work and being in public without significant residual swelling, that is going to be in the range of 2 to 3 weeks. It could be shorter or longer based on what one does and what activities one wants to engage in. This does not mean that all swelling is gone in three weeks, just a large part of it.  It takes up to three months after surgery for final swelling resolution and tissue adaptation to the implants to occur. This is as true for a chin osteotomy as it is for jaw angle implants.

From a discomfort standpoint, jaw angle implants are the most uncomfortable of all facial implants because the major chewing muscle (masseter) must be lifted up to put them in. It also affects one’s ability to chew well for a few weeks, again because of the masseter muscles being traumatized. A chin osteotomy causes more swelling than an implant and similarly takes up to three months after surgery to really see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe I need jaw implants from the gonial to the chin area. I have had a sliding genioplasty at the chin several years ago.  I have a short jaw bone that angles upward from the chin area to the bottom of the ear. I need to bring this to a more horizontal angle.

A: Thank you for your inquiry. It sounds like you have a pretty good handle on what you need. Ideally you need custom jaw angle implants that extend from the jaw angle right up to the chin area. Such an implant is not available as a stock or off-the-shelf implants. Off-the-shelf jaw angle implants will not reach the chin area, at best they will reach to the mid-body of the mandible behind the cut or notch from the prior osteotomy. That is an acceptable approach if one can accept an indentation between the chin and the jaw angles. But a completely smooth transition from the chin back to the jaw angles requires a custom implant approach based on a 3-D model mandibular model made from a CT scan. This is the best and only way to get a jawline that is completely harmonious fro one side to the other.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am going to get a facelift and chin implant at the same time. In remaking a new jawline (or a rejuvenated one), I thought that maybe jaw angle implants would be beneficial as well. Do you think it would give my jawline more definition?

A: My concern about jaw angle augmentation in your face is that the only effect it may have would be to make it look bigger/rounder/more fat. Your tissues are so thick over the parotid gland/jaw angle area that it would provide no definition and just bulk. And the last thing you need is more bulk/width in the posterior part of your face. Jaw angle implants work best in a thinner or already more defined face where the outline of the implants can be better seen. Jaw angle implants are not just about adding bulk. That result is often not helpful, and even detrimental, to the aesthetics of a fuller face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I took a look at the computer imaging that you did for me for my jawline. I like what you did to the chin but don’t like the jaw angle result. I saw a case of a guy onlione who had custom made jaw angle implants done and he did not had that square look. Is that possible to be done to me like that as well?

A: Let me explain the purpose of facial computer imaging. Initially it is to create a dialogue or communication as to what the patient wants. No knowing what anyone really wants when they say a stronger jawline, I have to have a starting point for discussion. I made those angles square to see if this is the tyhe of jaw angle look you prefer. They do not reflect any particular implant selection as of yet. Therefore, looking at other jawline examples is helpful only for the standpoint of giving me guidance as to what look someone prefers…it means nothing about the implant style. So custom jaw angle implants are not what you need. Custom facial implants are usually used when the final look is more extreme or when stock off-the-shelf implants can achieve the desired look if they are intraoperatively modified. When going for less than a square or flared jaw angle look, stock jaw angle implants will work just fine…and they are far less expensive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a jaw angle augmentation surgery done over a week ago and now that major swelling has subsided I’m noticing that my implants are way too big, they make my face look round, like a watermelon, and not long and squared like I wanted them to. My question is: can the implant be taken out, reshaped and placed back in? Do you recommend this or should new implants be ordered? Will the revision surgery have the same amount of swelling/downtime as the intial one? Thank you so much for taking the time to answer my questions.

A: Quite frankly, if I have heard these same concerns from one male patient who has had jaw angle implants, I have heard it from the last fifty. You are jumping the gun in trying to determine just one week out form surgery what the results will be. Jaw angle implants cause, by far, the largest amount of swelling of any of the facial implants. Patients generally swell up like a balloon and don’t even start to look human again until three weeks after surgery when maybe 50% of the swelling has subsided. I would not even try to judge the results obtained by these implants until at least six weeks after surgery…three months is even better. Swelling aside, there are numerous other factors which control the shape of the jaw angle afterwards including the original jaw angle deformity and what style of jaw angle implants were used. Size of the implants is one issue but style of the implant and where on the bone they were placed and how they were  secured is even more important. Patience is the key for now. It is just as ‘easy’ later to adjust or switch out the implants at six weeks or three months as it is now. You will only benefit by patient and more healing time to make the right decision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, because of an accident at an early age I had some weak chin and facial asymmetry on the right side. Four years ago I had a chin implant whichi resulted in horrible deep hollows on the side of the chin. My chin implant was a button type. So I’ve had three fat grafting surgeries to correc the hollows and also using fat to lessen the asymmetry. (underdeveloped right side of my face) The results are not bad but still lots ofasymmetry and the fat is starting to melt unevenly so I am looking for a more radical solution. I want to remove the button type implant and replace with an extended anatomical chin implant as well as jaw angle implants to look more solid. What is yourt suggestion about this? Thanks a lot.

A: I would agree that changing the chin implant to an extended style is much better for a male than a central button style. The jaw angle area could be permanently enhanced by lateral extension jaw angle implants. The only area that will not be filled in as well is the area between the two. But I don’t think in your case that would justify custom implants to be made. Fat has been a good intermediary step to see if the changes are favorable but it is definitely not a permanent solution. The combination of chin and jaw angle implants provides a permanent volume solution to jawline enhancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be interested in learning more about the jaw augmentation procedure  through the insertion of  mandibular implants (both angle and ramus). I know that it is usually not possible to estimate costs and length of recovery in patients that the surgeon has not had a chance to examine and talk to in person, but still, I was wondering if you could give me a (general) idea of how much the total cost of the surgery would amount to (all inclusive: implants, surgeon, anesthesiologist, facility etc.) as well as how long the downtime would be.

A: In answer to your cost question, part of the cost would relate to what type jaw angle implants are used. (silicone vs Medpor)  There are different styles and shapes based on the jaw angle result desired. But taking that into consideration, the total cost would be in the range of $6500 to $8500.

The concept of recovery after any surgery depends on how one chooses to define recovery. From a significant facial swelling standpoint, think three weeks. From judging the final result, it is a minimum of 6 weeks and ideally 3 months. From a physical recovery standpoint, one can return to work as soon as they feel able., which for most people would be 10 to 14 days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting the asymmetry of my face. The right side of it, particularly in the jaw angle area, is tilted upwards and shorter. I have read that a jaw angle implant may be able to correct this tilt.Would this implant make the right side look closer to the left and would I feel the difference? Would a cheek implant help along with the mandibular angle implant to even out the balance? I don’t want the right looking more full and balanced then the left.  Would braces help fix or improve the jaw tilt/angle?

A: In the ideal correction of facial asymmetry, it rarely is just one facial area that is shorter or asymmetric. In most cases of facial asymmetry, the entire side of that face is shorter. For this reason, jaw angle and cheek implants together are often done and produce the greatest amount of facial lengthening and correction of the shorter side.

Braces change how the teeth fit together but will not change the tilt of the jawline.

The goal of facial asymmetry correction with facial implants, the most common treatment method, is to try and get the best match between the two sides as possible. While perfect symmetry is never possible, the closer the two match the better. In the spirit of that goal, it is always better to be slightly less full than too full when deciding about implant sizes.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am looking for help in fixing facial deformities and asymmetries. I have been to an Oral surgeon and a Maxillofacial surgeon before but they didn’t seem to care. I have a right sided facial deformity that bothers me alot. I would like to find some help for this problem. The right side of my face is under developed and I can see it and even feel it. My left and best side is more fuller and straighter.  My right side is smaller and recessed and less defined. Can an angled tilt in the jaws on one side be fixed? I have attached some pics for you to see.

A: Thank you for sending your pictures. I can see quite clearly the tilt to your jawline and the less full right mandibular angle area. It is not possible to cut the jaw bone and angle it downward without changing your bite on the right side. But it can be more simply and effectively treated by a mandibular angle implant, using specifically a type of jaw angle implant that extends the length of the jaw angle downward as well as making it more full. This would be done through an intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I plan on getting a rhinoplasty, chin, cheek and jaw angle implants this summer. It makes sense to me to have them all done at once. I have limited time off from work and only have a few weeks to recover at this time of the year. The one plastic surgeon I saw said he wouldn’t do them all at once as it would be too hard on me. I am not sure what he is talking about as I am young and healthy. I am aware that doing more surgery increases the overall risk of potential problems such as infection, but are there other risks to be taken into consideration, such as blood loss, that I am not aware of? Do you think it is safe and reasonable to have all of these facial procedures done at the same time?

A: In my experience and practice, I routinuely perform three, four, five or more facial procedures at the same time. For the reasons you have mentioned, such as recovery and other considerations such as cost, it is desirous to do a ‘facial makeover’ as a single stage procedure. There are no increased health risks for doing combination facial surgery in an otherwise healthy person. Blood loss is not a concern. With that being said, there is one risk that occurs in multiple facial restructuring procedures particularly those that involve facial implants…an increased aesthetic risk of implant asymmetries and the need for revisional surgery. The more procedures you do, the more risk there is for less than perfect results. Each individual procedure comes with its own aesthetic risks which are increased as more procedures are combined. Patients need to appreciate that the likelihood of the need/desire for revisional surgery is multipled as procedures are combined.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had a chin implant which was done four years ago. Now I want to get a jaw angle implants to achieve a subtle outwards projection and a slight vertical projection such that the lower 1/3rd of the face becomes ever so slightly longer in the back. I only want subtle changes and do not want a very prominent square jaw. Instead, I want to retain the V shape ending of my lower 1/3rd of the face but just slightly stronger. Am I correct to assume that this can only be achieved through custom implants?

A:You are not correct in assuming that custom jaw angle implants would be needed to achieve your goals. While they could be done in a custom fashion, it would be more cost effective to modify existing stock jaw angle implants. Custom facial implants are almost always done when the size of the facial projection needed exceeds those implants which are commercially available. You are going the opposite and more favorable direction. Based on your description, I would recommend Medpor RZ jaw angle implants, small, which could be intraoperatively modified to 3mms lateral width extension and 5mms vertical length extension. That is about the size to me that you are talking about when you mean subtle increase in jaw angle projection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had injectable fillers placed along the back side of my jaw to give me more of a sharper angle appearance. It was Radiesse and it took two full syringes to get a modest effect. The result was good but I wished it was stronger and more pronounced. I have heard that if you keep getting the fillers they will build up overtime and you will get a permanent effect. Is this true? If it is not, then do you think jaw angle implants will give me what I want?

A: There are no synthetic injectable fillers currently approved in the U.S. that are permanent. So it is not true that repeat treatments of any injectable filler will lead to a long-lasting build up of any facial bone site. Most certainly injectable fillers are not a substitute for the volume and permanency that can be provided by jaw angle implants. What your injectable filler treatment has done is to demonstrate that augmentation of the jaw angle region is aesthetically beneficial for you. That can be very helpful when uncertain if such a facial change is worthwhile. This should give you the confidence of proceeding forward with this implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi. My jaw points down and my chin is very weak. I would like my jaw to appear more square shaped. I don’t think this is a problem with the growth of my jaw as my bite is excellent and I wouldn’t want to mess with it anyway. I considered a chin implant but that seem to just make my jaw longer as it would sit on a backward angled segment of bone.  Also, my nose has a high bridge, so I am wondering if rhinoplasty might off set the look of the jaw. Right now, my jaw line and the bridge of my nose are almost parallel lines. What is your suggestions?

A: In looking at your pictures, your mandibular plane angle does parallel the dorsal line of your nose. This is not a nose problem as its shape and size looks good. A rhinoplasty you most certainly do not need. You need to reorient the plane of your mandible. This would be best done by a combined chin osteotomy and jaw angle implants. The chin osteotomy would bring the chin forward but would also bring it upward due to the angle of the osteotomy cut. This will actually shorten the vertical length of the face. The jaw angle implants will bring down or lengthen the ramus of the mandible of posterior length of the face. These two procedures together will create a counter clockwise rotation of the mandibular plane angle.

Dr.  Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am primarily concerned with the lower third of my face. I think my chin is too long and pointy which contributes to the long, thin face look. Do you think a chin reduction combined with jaw implants or a pre jowls chin implant would do the trick? If so, do you perfom such procedures? Do you have any other suggestions as to how I could improve my facial features? Please do not be afraid to hurt my feelings!

A:Thank you for sending your pictures. Your long thin face is partly the result of a long sweeping jawline with a modestly steep mandibular plane angle.  This makes for a lower face that appears vertically long. This is magnified by the observation that your midface (cheek and paranasal areas) is relatively flat/recessed. That combination makes for what you see,, a face that has a greater vertical component than horizontal projection and width.

To address this concern, I would recommend a chin osteotomy which, based on the angle of the cut, allows the chin to become vertically shorter as it comes forward. You need both a mild amount of horizontal increase with an equal amount of vertical reduction. Only an osteotomy can make this bony chin movement possible. In addition,. I would place jaw angle implants that both widen and vertically drop the jaw angles downward. Between the chin and the jaw angle changes, the lower third of your face would become shorter and wider. That will help counter the long thin face look. I have attached some predictive imaging to illustrate these changes.

The other change that would be helpful is cheek augmentation. That would bring the midface more forward, again a manuever that counters the vertical and thin (horizontally deficient) facial appearance. I have attached an image that shows where this cheek augmentation would be. Your pictures are not of a good enough quality to really show what cheek augmentation can do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, You have some great results for jaw augmentation! For the man pictured below, what biomaterial did you insert and were they custom made implants? If not, what kind and shape of implants did you use? And how many mm width and length? My facial shape is somewhat similar to the man below after a botched jaw reduction surgery. By the way, since there is bone erosion over time with these kind of implants, I was wondering if this will be more of an issue since I had my outer bone removed, leaving the marrow or softer bone inside exposed. Also, since my softer bone is exposed, would there be higher chances of infection?

A: Those are preformed lateral augmentation silicone jaw angle implants. Although in someone with missing angles from a jaw reduction, you may be better off with an inferolateral style (Medpor) which is better at creating a more defined jaw angle. Otherwise, I am not aware that there is any bony erosion with jaw angle implants. I have removed many from other surgeons over the years and have never seen that issue. Having had jaw angle reduction previously, this does not increase your risk of infection or difficulty with jaw angle implant placement in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in creating a more symmetrical look to my face via fillers and eventually implants. As a result of my jaw being asymmetrical, the right side of my lower face appears fuller and more defined than the left. Additionally, my upper jaw is recessed. I have consulted with oral surgeons but none believe my problems are severe enough to warrant jaw surgery as my jaw is fully functional. What do you recommend?

A: The use of injectable fillers does have a role in facial reshaping/contouring but it is more limited than most patients appreciate. Because of the volumes of fillers needed to create visible facial contour changes and their temporary effects, the use of fillers must be done judiciously. For lower jaw asymmetry, and particularly for midfacial flattening, injectable fillers have very little role to play in a long term improvement strategy. Lower jaw asymmetry is often the result of a smaller jawline or mandible on one side. That is best addressed with the consideration of a jaw angle implant. Midfacial flattening, particularly done at the upper jaw level (maxilla, LeFort 1 region), needs horizontal volume augmentation. This is best done with either paranasal, premaxillary or both types of lower level midfacial implants. These would be far more effective than any type of synthetic filler injections.

Dr. Barry Eppley

Indianapolis, Indiana

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

Indianapolis, Indiana

Q:  Dr. Eppley, I have a short face length with a small/narrow lower jaw. From the profile view my face looks even shorter because of my short forehead and short jaw. Could jaw implants fill out my lower jaw and make my lower/overall face look ‘bigger’? I’ve already had a chin implant, but it didn’t do much for vertical length. My plastic surgeon says a sliding genioplasty wouldn’t look good.  Should I get a second opinion? Is it safe to get a sliding genioplasty and jaw implants at the same time?  Thank you for your time.

A:  The right style of jaw angle implants will vertically lengthen the posterior face. But the wrong style of jaw angle implant will only make it wider (fatter) and not longer.

Chin implants will not provide any vertical length, just horizontal projection. No stock chin implants are made for vertical chin elongation.

The statement that a sliding genioplasty won’t look good is a nonsensical opinion. A sliding genioplasty is the only option to provide vertical chin lengthening or lengthening of the anterior face. Just because a surgeon can’t do an osteotomy doesn’t mean it won’t look good or be a good choice for a particular patient.

It is common in my experience to do jaw angle implants with a chin osteotomy and/or an implant. They are often needed together to create an overall change in jaw shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in getting cheek and jaw angle implants. My jaw angles are very steep which got worse after jaw surgery for a bad bite several years ago. My cheeks have always been flat and I get Radiesse in them which makes them look better. Can you tell me what types of implants I should get and what are some of the complications that could happen that I should be aware of. I have attached some pictures for you to see what my face looks like.

A: Thank you for sending your pictures. I have reviewed all of them. The key to your successful facial implant surgery is to have appropriately-sized implant selections. For the cheek area, you would benefit by implants but they must be small to not overwhelm your feminine face. Small malar shell style would work well for your face. For your jaw angles, you need implants that provide some vertical lengthening but minimal width increase, otherwise you will create a wider fatter face and not a nice jawline enhancement that fits your face. Small Medpor RZ angle implants (3mms width and 10mms length) should work nicely, but no bigger.

Implants should be placed that fit the face. As it turns out cheek and jaw angle implants are the most highly revised of all facial implants. The problem with many cheek implants is that they are too big. The problem with many jaw angle implants is that they are improperly positioned and/or secured.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for an opinion regarding correction of my steep jaw line. I had orthognathic jaw surgery in 1998 to correct an underbite, but over the years I feel that the angle of my jaw has gotten steeper, giving my profile a “harsh” look. A doctor has suggested jaw angle and cheek implants to balance out my chin and soften my face. I am hesitant to go under general anesthesia and am concerned with the risks of the procedure and, most importantly, whether it will improve my look. I was told that another option is filler in the jaw line, but that an implant would provide more correction.What would you recommend for me? Do you think that jaw angle implants would improve my look? Do you think I could achieve good results with just filler? After going through orthognathic surgery, I was hoping to have achieved a better result and I feel self conscious about my jaw line. I have attached some pictures for you to review.

A: Based on the viewing of your side profile, your jawline is characteristic for someone who has had a mandibular setback osteotomy for a Class III malocclusion due to an original mandibular prognathism. This can adversely shorten the jaw angle and increase its plane angle. I can understand the proposal of jaw angle and cheek implants to give your face more skeletal balance. The real questions are, however, will it make a positive change and is it worth undergoing surgery for it.

There are two ways to provide insight to those questions. First, computer imaging should be done with jaw angle implants alone and then combined with cheek implants. While computer imaging is an estimate and not a guarantee, I have always found it very helpful for prospective patients. I have done that for you and it is attached. These are based only on a side view. The front view you have provided is not good for imaging because you are smiling and it doesn’t show the jawline/angle all that well. The three-quarter or oblique view is the next most helpful view to evaluate. Secondly, injectable fillers can be an alternative to see if the concept of implants would be appropriate. When placed next to the bone they can provide some bone augmentation. But they will never produce the same effect as adding implants because of the sheer volume differences. Injectable fillers are never a comparative substitute for facial implants but they may provide some insight into whether bony augmentation is the right concept. If one is not absolutely certain that implants are the right answer, try fillers first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had in orthognatic surgery several years ago for a bad bite that gave me a lot of problems with my teeth and pain in my jaws every morning. While the surgery went fine from a technical standpoint (my bite is better) it left me with a very bad look. I think it is because he made some mistakes with repositioning the masseter muscle as my face shrunk on the sides and left me with a lot of loose skin. This makes me look 10 years older then my age. I’m now 50 and I look older. I am used to always looking much more younger than I am. I’m very unhappy and I don’t think normal lifts of skin will help because what is missing is underneath, it needs to be filled in. I need deep tissue filling not just stretching the skin. Here are some photos for you to see what I mean.

A: What I see on the photos is lack of jaw angles and loose jowl and neck skin. The jaw angles actually appear both high and indented or concave. I think the jaw angle issue is a result from your orthognathic surgery but it was not a mistake by the surgeon. Mandibular osteotomies involves elevating the masseter muscles off of the bone to perform them. There is no such thing as having to reposition them during the surgery as they simply fall back into place. But what can happen is muscle atrophy/shrinking from the trauma of the surgery and I believe this is what you have experienced. Because of the lack of a jaw angle, you would benefit by small lateral augmentation style of jaw angle implants. This could be combined with a limited neck-jowl lift (facelift) to create a more youthful jawline and nek appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a steep angle from the back of my jaw straight to the chin. It looks very odd to me although no one else seems to notice strangely enough. I know it is not very common in women but I think a jaw angle implant would work well to make this look better and give my face more balance in profile.
 
I also have issues with a very bad rhinoplasty as you will see in the attached pictures. If you could simulate a nice straight nose with a nice narrow tip and not so ‘turned up’ I would very much appreciate it Out of interest, is it possible to make the sides of the nostils narrower to give the appearance of a narrow nose or is that not really worth it?
 
 Attached are a couple of pictures they are not great but I don’ t have any digital pics. Thanks for giving me an opinion.

A:  As you surmised, on reviewing your pictures, you do have a high jaw angle and a steep mandibular plane. I have done some imaging which demonstrates the effect of a vertical lengthening jaw angle implant.

 From a rhinoplasty standpoint, your nose shows a bulbous tip, a pinched middle vault and a still wide nasal bone area. The side view shows too much upturning of the nose and some nostril rim retraction. I have done some imaging with a rhinoplasty that includes nasal bone narrowing, middle vault spreader grafts, tip narrowing, tip derotation, alar rim grafting and nostril narrowing. This will give you a more balanced and narrow-appearing nose.

Dr. Barry Eppley

Indianapolis, Indiana