Your Questions

Q: Hi there. I tried to send a photo over for the 3d imaging but it didnt send unfortunately – said I hadn’t filled in all fields but they were all complete.Was after some advice really. I have had maxillofacial surgery because I had an under developed bottom jaw. This included a genioplasty too. However, since having the genioplasty my chin looks really long to me when I smile, especially from the side. My jaw bone is only a cm under my ear. Would jaw implants in this area improve the look of the length of chin do you think and widen the lower face a little?

A: When an osteoplastic or sliding genioplasty is done, the vertical dimension of the chin almost always increases. That is because as the chin is brought forward there is a natural tendency to open the ‘wedge’ of the osteotomy or it may be deliberately done to actually lengthen the chin as well. That is part of the presurgical planning. If a genioplasty is done with a mandibular advancement osteotomy (jaw brought forward) that may leave the posterior height and width of the mandible deficient. This would be evident by a steep mandibular plane angle between the bottom of the jaw angles and the bottom of the chin. In these cases, I have done jaw angle implants whose primary goal is to increase the vertical dimension of the jaw angles more so than adding width. Much jaw angle width is rarely needed in most females.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am interested in getting chin and jaw angle implants. I would like the chin implant to be lengthened (to the most extent) and squared (to the most extent) being in the category of the latest style available on the market. The jawline height should be lengthened and widened to its proportionate maximum possibly by having a “wrap around” implant and/or separated combination of implants. Do the latest style chin implants stating the above written factors of width and length fit the “wrap around” implant or separate implants more accordantly?  Thank You.

A: In answer to your questions about chin and jaw angle implants, here is the following dimensions:
Square Chin implant (Style 2 Terino), Implantech =   6.5mm anterior projection in the middle, 10mm projection on the square portion (transition corner) of the implant, 9cms long (4.5 cms back from the middle on each side)

or
RZ Extended Square Chin, Medpor = 7mm in anterior projection, 11mm projection on the square portion of the implant. Because of the central connector, the implant can be expanded and made more square which also allows for the creation of central cleft

RZ Mandibular Angle Implants, Medpor = 11mm width expansion, 10 mm vertical elongation

These three implants must be put together to create a ‘wraparound effect’ but there will be a depression between the two along the jawline because their edges are feathered where they come together. They were never made to be used to create a completely smooth wrap around jawline effect. What you may really be searching for is a custom one piece wrap-around jawline implant that can be made to almost any shape and dimension.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am requesting male masculinization including cheek and jaw implants. I want a  “wrap around” jaw implant with a very good cleft in the chin portion.. I would like a widened, elongated and very distinctive jawline angle and very shapely square chin, preferably the most square chin implant. I would also like that fine line of distinction between the lower part of the jaw implant and the chin implant. A line that is located on the sides of the mouth maybe about an inch from the corners giving the jaw and chin a very strong look when implants are placed together. I’m hoping this can be accomplished by using a “wrap around” implant without too many additional implants.  Can this be done and with what type of implants? I have attached some photos for you to see my jawline.

A: When it comes to your jaw, I understand what you want to achieve as far as jawline enhancement is concerned. While your jawline and chin is by no means weak, it appears you want it to be more pronounced. When it comes to doing a complete jawline enhancement or ‘wrap-around’ augmentation, there are two fundamental implant approaches. The first is to use three or a triple implant approach. This would be a chin and two jaw angle implants. The weakness or flaw to this approach is that the union of the wings of the chin implant and those of the  front edges of the jaw angle implants is a weak contour area. It is never filled in as well as the chin and jaw angle prominences, particularly when the chin is more square in design and the jaw angle are more pronounced. The other approach is to make a custom jaw implant as a one-piece unit. (even though it may be put in as two separate halfs and combined in situ) This avoids the body of the mandible contour defect from the triple implant approach. Its one drawback is that this is a more expensive method as the custom implant has to be made off of a 3-D mandibular model prior to surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in correcting some asymmetry in my face and creating more harmony to the lower third of my face. The back of my lower jaw area (masseter muscle) is bigger on my right side. There is also some soft tissue asymmetry with the right side being fuller in my mid cheek area, and my chin is off center. I have been to different cosmetic surgeons but have not come across anyone who has a real solution for this. Orthognatic surgery was recommended, however I believe there is a way to correct this without such invasive surgery. I have had trouble locating a doctor in my town that does jaw implants, that’s why I was happy to find your site because it seems jaw angle implants and dealing with facial asymmetry and the jaw area in general is something you have extensive experience. I have done some research, and the solution I came up with would be jaw angle implants, with the one on the right side being bigger to account for the asymmetry. However, even without the asymmetry I would still be considering jaw implants, just because I feel that my jawline is more narrow/less defined than I would like. For the soft tissue asymmetry I would like to do removal of the buccal fat pad/or facial liposuction to thin out the lower cheek area of my face and make that area more defined. Please let me know what you think. I look forward to hearing from you and getting an idea of what you think is best from the imaging. Thanks!

A:  Thank you for your inquiry and sending your photos. As you have astutely pointed out, you have overall lower facial asymmetry marked by a very high left mandibular angle (steep mandibular plane) compared to the right side and chin bone asymmetry. This could be improved by jaw angle implants (3mm lateral style on right and 3mm inferolateral style on left) and chin bony contouring. (right chin tubercle reduction) For the midface, I would look at not only buccal lipectomies but the addition of small cheek implants as well. When you have a long face that is flatter in profile (malar hypoplasia), some anterior projection of the cheeks is helpful. Otherwise, buccal lipectomies alone may just make you look a little more sallow or gaunt and not provide the facial highlighting that you desire. 

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello Dr. Eppley, I am interested in having a stronger structured jawline. I have been wanting this and am now prepared to have this done. I am tired of seeing a round fat face and with your expertise I think I can get the sculpted jawine that I have always desired. Here are some pics of myself and pics of jawlines that I want to look like. I think my jawline needs to be built up with a chin and jaw angle implants. Let me know what you think.

A:Thank you for sending your pictures. I have reviewed them and done some realistic computer imaging. My comments are as follows:

1) A big reality check is needed here. You can not get to or look like any of those examples. You have a completely different anatomy and skin and fat thickness of your face. While an admirable goal, it is not realistic. You can be improved and maybe end up about halfway between where you are now and those examples. All I can do is take what you have and make it more defined as much as possible.

2) A square chin implant will help the front of the jaw. Your chin needs to come forward and down to become the leading point of your face.

3) You need aggressive neck and side of the face liposuction with removal of your buccal fat pads. As much facial defatting needs to be done as possible.

4) I do not think that jaw angle implants will help you. You don’t need a wide lower jaw in the back. It is plenty wide, you need better definition of what you already have. Jaw angle implants will just make your face look fatter with no better definition.

Dr. Barry Eppley

Indianapolis Indiana

Q: I have a problem with the shape of one side of my jaw. I had a fibular free flap surgery done several years ago as a result of an osteosarcoma tumor that was removed from my right bottom mandible. I have since recovered nicely from surgery and I now have dental implants. However, one thing that bothers me from the surgery is that my right bottom mandible is not in alignment with my left bottom mandible. My left mandible is defined and square whereas my right mandible is “heart-shaped.” Side pictures of me are especially embarrassing as well as the stares I get from strangers. What can be done to give me a more normal shape to the reconstructed side of my mandible?

A: Having dental implants placed into a mandible reconstructed with a fibular free flap suggests that you have had a very successful outcome. It takes good bone stock and alignment of the reconstructed jaw segment to the upper jaw to be able to get such dental reconstruction. I suspect that the deformity to which you refer is that you have no defined angle of the mandible on the reconstructed side. This can happen due to the take-off of the fibular graft from the ramus of the mandible. The joining of the fibular bone flap and the remaining mandibular ramus forms a new jaw angle. If this is not done at a 75 to 90 degree angulation, the jaw angle will be blunted or more obtuse. This can be confirmed by a panorex dental film, which you undoubtably have from your dental implant reconstruction, which shows the entire mandible and its shape from side to side quite clearly. This could be improved by the simple placement of a jaw angle implant. This would be best done through your existing neck incisions.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi Dr. Eppley. I am considering going to you for facial surgery, but I am unsure about exactly what procedure is necessary. All I know is this: I am a male with a long, narrow face. Can jaw angle implants make my face look more wide and more square-shaped? I am interested in making my face seem less long and vertical.

A: Thank you for your inquiry. Jaw angle implants do make the lower jaw more wide and square-shaped which may, or may not, be beneficial in helping you improve your long and narrow face appearance. That question can be answered by computer imaging. By simulating the results of the surgery on your own images, you can visually get the answer to these questions. If you send me some photos (front and side of your face on a clean background such as a wall or door), I will do the computer imaging so we can see if jaw angle implants are beneficial for you. Once we see the results, we will know if jaw angle implants or other facial implant procedures may be beneficial.

It is true that one way to change the illusion of how a face appears is to change the alternative or perpendicular dimensions. Therefore, vertical facial length may be counterbalanced by increasing facial width or forward facial projection.

Dr. Barry Eppley

Indianapolis Indiana

Q: With all of the jaw angle implants that you have placed, what are the most common complications? What problems have you see long-term? Are they permanent or would I need another in future?

A: Jaw angle implants, in my experience, are uniquely different than all other types of facial implant locations. Because they are put under the biggest muscle in your face (masseter muscle), and the only facial muscle that actually moves a bone (mandible, lower jaw), there is more discomfort and recovery from the procedure than any other facial implant procedure. The sides of the jaws are fairly swollen and the mouth will not open normally for a few weeks. (trismus) This is due to the stretching and trauma to the masseter muscle. Because it is a large implant that is put in through the mouth, the risk of infection seems to be higher than any other facial implant.  Despite doing  every infection precaution available, I have found that the infection rate is about 5% of all patients implanted, necessitating removal and/or replacement. The other complication risk is asymmetry. Because the implants are on opposite sides of the face, it is challenging to always have a perfectly symmetric result. (many patients don’t have jawbone/angle symmetry to start with) This leads to a revision rate for symmetry correction in jaw angle implants of around 5% also. Collectively, this means that one out of every ten jaw angle implant patients will need some sort of revisional surgery. These complications are seen early within the first few weeks to several months.

On the good news side, jaw angle implants are permanent and will not change over one’s lifetime once successfully implanted amd healed into place.

Dr. Barry Eppley

Indianapolis Indiana

Q: Thank you for reviewing my photos and my desire to make some facial changes, particularly that of my jaw line. In looking at your computer imaging predictions, the jaw angle implants seemed to have lengthened my jaw angles quite a bit in the side view. I like the shape of my jaw for the most part and was looking mainly to add width from the front view.  I know there’s only certain jaw angle implants available so would that be possible or even advisable?  Also, do you think I’m a candidate for chin implants?  I’m now thinking those may help as well.

A: Thank you for your comments on the computer imaging as that clearly tells me what the right style of jaw angle implant/change that you desire. The one I depicted was the style known as an inferolateral jaw angle implant which does just what you have described and seen, it makes the jaw angle longer and wider simultaneously. Having seen that you have described and preferred what is known as the other jaw angle implant style which exists known as a lateral projection or width only style. That is a very distinct jaw angle implant style and is easier and less traumatic to place as the tissues at the lower border of the jaw do not have to be stripped off to place the implant.

 As for chin implants, there are a half dozen styles that make different chin dimensional changes. What type of chin change do you think you would like? That helps in selecting the best type of chin implant style for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am going to undergo orthognathic surgery in the coming year. My maxilla will be brought forward as well as my mandible. This will also help my sleep apnea problem. I was told with the advancement of my maxilla, my nose would move as well. That is why I am also having a rhinoplasty. It is supposed to be more of a tweak. To complement my mandible, a sliding genioplasty will be performed. I also have incompetent lips, so a v-y advancement of mu upper lip will also be done. What are your thoughts on the mandibular angle implant? I want more of that model look that I read about on your blog. Will it look right on me? Is my facial geometry even capable of changing with a mandibular angle implant to what I desire? Am I being too ambitious?

A: In answer to your questions, my overall statement is that you are being overly ambitious as you have already admitted. While jaw angle implants would be beneficial from a facial shape standpoint, it should never be done in conjunction with orthognathic surgery. That would require the implants to be placed directly on top of or next to the sagittal split mandibular osteotomies. That would be a recipe for infection and the potential to interfere with the healing of the mandibular osteotomy sites. In essence, a disaster from a jaw healing standpoint. While that may not happen, it is a real risk and one that isn’t worth it.

 You need to go through the orthognathic surgery and adjust to your new face for a full year and allow everything to heal well. Only then should you reconsider jaw angle implants through computer imaging and further facial analysis. 

Dr. Barry Eppley

Indianapolis Indiana

Q: I’m a little self-concious about my lower face.  I am now 48 years old and feel lilke the sides of my jaw are lacking. When I was a teenager, I had orthodontics which included removal of four permanent teeth to make room for other teeth. This moved by front teeth and my back teeth forward to close the space. Now that I’m older, I’ve come to believe that I have a shallow jaw because of this earlier orthodontic treatment.  I would like some jaw angles as I think my jawline is too steep. From my chin, my jawline just goes straight back and up towards my ears without any definition to the back part of my jawline.

A: For what it is worth, your prior orthodontic treatment (which was and still is standard in many patients) is not the source of a steep jawline. A steep jawline is when the angulation from the jaw angle down along the inferior border of the mandible to the chin is greater than 15 to 20 degrees, often approximating 35 to 40 degrees. As long as the teeth satisfactorily come together, this is an aesthetic issue that is the result of high or underdeveloped jaw angles.

Jaw angle implants can make a big difference in the aesthetics of the jaw angle and jawline. but it has to be the right type of jaw angle implant. It needs to be the type that will lower the jaw angle and not just simply make it wider.  In general, jaw angle implants can lower the prominence of the jaw angle by 1 to 2cms with standard off-the-shelf implants.

Dr. Barry Eppley

Indianapolis Indiana

Q:  My problem is that one side of my actual jawline is naturally lower than the other. I had jaw angle implants placed and now it looks worse. The look, now with the implants, is even more asymmetric and unbalanced. The shorter side needed to be lengthened but, with the conventional Porex implant selection, obviously that was not possible. It looks like I will need to pursue the CT scan and customized implant option, yet my concern is not only the price, but also when this will need to be dealt with. I know these types of implants unite with the bone tissue quite strongly and as years go by, it becomes even more difficult to remove them from the face. I know it causes a great deal of trauma and involves a lot of risk on both the part of the patient and surgeon. I would appreciate your thoughts and help.

A: While the custom approach is certainly a possibililty (it adds about $5000 onto the procedure to get the final implants in hand and sterile), I am not certain that may be exactly what you need based on your description.

It sounds like asymmetry was the original issue and that is now exaggerated because of the implants used. Contrary to your perception, there are six different styles of jaw angle implants from Porex some of which are lateral augmentation and others which are inferolateral augmentation types.Choosing a different style of implant for each side may well have made for a better result. When asymmetry exists, it is important to first get a panorex film to look at the height and shape of the jaw angles. Then one can decide if the existing off-the-shelf implants may suffice.

As for secondary surgery on Porex implants, I have not found that it is unduly difficult to remove or that it has ever grown to the bone. Much is talked about that concern, but it is largely overblown in my experience. Yes it is much more ‘difficult’ than removing silicone implants, which by comparison slide right in and out, but it is not impossible or causes significantly more tissue trauma than that of the original implant surgery. All synthetic implants get a scar capsule around them. That capsule with Porex implants is more adherent due to some tissue ingrowth. But they do not unite with the bone or become part of them as an onlay implant.

Dr. Barry Eppley

Indianapolis Indiana

Q: I recently came across an article written by you regarding jaw angle implants for male patients. I went through this particular surgery and I am saddened to say I am not exactly happy with the results. It is a tough situation to be in, but now I realize I should have pursued a CT scan and customized implants, though it was not an option for me or the doctor who treated me at the time. What do you recommend for me now?

A: There are multiple reasons why dissatisfaction can occur after jaw angle implant surgery. The two main reasons are implant size and implant style. Like any implants placed anywhere in the body, they can end up being too big or too small. But that is not the impression that I am getting about your dissatisfaction. Implant style, or how the implant actually changes the shape of the jaw angle, is actually the most common problem. One type of jaw angle implant merely makes the existing jaw angle wider, known as lateral angle augmentation. Most men interested in improving their jaw angle definition, however, don’t suffer from an exclusive width problem. They are interested in a wider and more defined angle which means extending the angle lower as well. That is a different jaw angle implant style, known as inferolateral angle augmentation, and is more difficult to surgically place. Getting lateral jaw angle augmentation when you really need or want inferolateral jaw angle augmentation will only make your jaw look puffy and wide and not get that more sharply defined angle that many men are seeking.

The other jaw implant problem is when one really needs vertical lengthening of the entire lower jaw line but they end up getting lateral jaw angle implants. Vertical jaw implants are ideally made on custom basis for each patient off of a 3-D model from a CT scan. But a combination of an inferolateral jaw angle implant combined with a prejowl chin implant may suffice in some cases.  Since you mentioned a CT scan and custom implants, this may be the problem to which you refer.

Dr. Barry Eppley

Indianapolis Indiana

Q: I hope you can help answer some questions about chin/jaw implants please? I have a weak jaw line in that my bottom jaw is slightly further back than that of my front, if you follow. I was wondering if I would be a candidate for a chin/jaw implant and if you believe this would assist in aligning my jaw whilst avoiding a lower jaw construction which I would rather not go through?

A: Small horizontal chin deficiencies are usually the result of lack of bone growth in the chin area only. (symphysis) More significant chin deficiencies, however, are a problem with the growth of the entire lower jaw (condyle, ramus and body), meaning that the whole jaw is short not just the chin. This can be clearly evident by how one’s teeth comes together. In a jaw deficiency, the lower teeth are offset behind the upper teeth by a 1/2 to full tooth. (known as a Class II malocclusion) Chin augmentation, whether done by an implant or cutting just the chin bone, improves the projection of the chin and the facial profile but does not align the entire lower jaw.

Aligning the lower jaw, by bringing the entire jaw forward that contains the teeth, provides chin enhancement but also improves one’s bite (occlusion) as well. This is most commonly done by a sagittal split osteotomy of the lower jaw which is performed in the ramus of the mandible. It is clear to see that jaw alignment and chin augmentation are the not the same thing. Jaw alignment by bone advancement will simultaneously give chin augmentation but chin augmentation alone will not create a lower jaw alignment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have looked into chin implants and, a local plastic surgeon with whom I shadowed in town, felt that a simple chin implant would only bring the skin forward in the front and not actually give me the square, fuller  jaw, and more forward chin, I was looking for to balance the face. So my question would be, is chin and jaw augmentation the same thing or are they different procedures? If they are then would “chin” augmentation be my best bet?

A: Chin and jaw augmentation are different but related. Chin augmentation refers to building out the front part of the chin or jaw, otherwise known as the anterior prominence. Jaw augmentation most commonly refers to jaw angle implants which accentuate the size and prominence of the posterior jaw prominence. While they are often done separately, it is not rare to have them both done at the same time to get a total jawline enhancement effect. A chin deficiency is frequently part of an overall ‘weaker’ jawline, so the three point augmentation approach (one chin, two jaw angles) can create a better defined and more masculine lower third of the face.

While jaw angle augmentation exclusively uses implants, chin augmentation can be done with implants or by moving the bone known as an osteotomy. Whether one is better served by a chin implant or a chin osteotomy, and the size and style of jaw angle implant needed, requires a careful facial assessment and the use of computer imaging to make those determinations for each individual patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 20 yrs old. I would like some advice on jaw angle implants. I want a more defined angular jawline. I feel that my jaw is disproportionate and makes both my nose and forehead appear large. Also I would like to see about a rhinoplasty because I have a hump midway up my nose. Thank you for your time.

A: A small jaw shape or jawline can make even well proportioned other facial features seem ‘big’. Since the features of a face are all interacted to make an overall appearance, it is not surprising that an imbalance in one part of one’s facial anatomy makes other parts seem out of balance. It may well be that the nose is too big or overprojecting as well  and this will conversely magnify a shorter jaw.

Understanding how one facial feature impacts another is best played out for each patient through computer imaging. By just changing one feature, such as the chin or nose, one can appreciate whether the primary focus of facial restructuring should be.

Like the nose and chin, the jaw angles lend themselves well to computer imaging. Changes can be easily visualized in both front, oblique and side views to see if jaw angle implants would be facially beneficial. When imaging jaw angles, it is important to look at both an increase in jaw angle width as well as jaw angle vertical lengthening. It is this vertical angle lengthening that is often underappreciated or forgotten when considering this facial prominence change.

Dr. Barry Eppley

Indianapolis Indiana

Q : Hi, I read online that other girls have the same problem as me. I had a jaw reduction and the doctor shaved too much bone and side of the jaw, is uneven to the other side. You gave advice to them to have jaw implant. My question is that since the jaw is now uneven, how can you make it even by putting jaw implant? Will the implant be different since it is not the same? How much does it cost for chin augmentation? Not the implant but the moving if the chin. Thank you. 

A: It sounds like you had a jaw angle reduction. Often times, too much bone is removed and the sides are uneven as more bone is taken from one side than the other. The only way to improve that problem is to replace the lost bone with an implant. The size and shape of the jaw angle implant is taken from tracings off of a panorex x-ray as both implants can not obviously be the same when asymmetry is involved.

Jaw angle reduction must be carefully done as it is easy to remove a large bone segment from this intersection of the posterior and inferior border of the jaw. This not only makes the jaw angle blunt but can make one look more aged as well.

A chin osteotomy is done much less frequently than an implant for chin augmentation. But in the right patient, it can offer some different dimensional changes that may be more ideal for facial balance. (e.g., chin lengthening) The average cost for a chin osteotomy is around $6500 when done as a one hour outpatient procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had cheek implants 3 yrs ago which I am looking at having revised. I am tall and athletic and they are just giving me a bony gaunt look to my face which also makes my eyes appear too far apart. What I really wanted in the beginning were midface implants, but wasn’t able to make this clear with the doctor. They are screwed in and I am wondering if they can simply be reduced or shaven down? Also I have jaw implants and am not happy with the square shape that has resulted from their outcome .

A: Facial implants today come in a wide variety of styles and sizes. They are far more versatile than just augmenting the chin, cheeks or jaw angle in a single way. Frequently, I have patients come to my Indianapolis plastic surgery practice that have existing facial implants but did not end up with the result that they wanted. Communication and computer imaging is key in facial bone augmentation with implants.

Both cheek and jaw angle implants can certainly be modified, exchanged, or simply removed. The question for both areas is what is the best strategy to achieve your goals. From a cheek standpoint, you may have been more interested in submalar implants (on the underside of the cheek bone) rather than malar implants which sit on top. They create different looks. With the objective of improving a gaunt looking face, submalar augmentation is preferred. Malar implants will actually make that appearance worse. In jaw angle implants, the size may be too big or their position on the bone may be too high or too low. The style and shape of the implant can also affect how square or sharp the mandibular angle is.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am considering getting jaw angle implants and have some basic questions. I want the Medpor RZ angle implants but don’t know if 3mms or 7mms width is the best for me. How can I decide? Will looking at patients with each size implant in help? Also, what is the recovery from this surgery like? I am having a hard time finding helpful information on the internet. Thanks!

A: It is tough to say which size is really best for any patient when you are looking at a 4mm difference in lateral projection. (0.15 inches) In different people with varying anatomies, the look can be quite variable. The best way to approach this question in your mind is…would you rather error on being a little too small or a little too big. While I obviously want a perfectly sized result, sizing is still an art form and not completely scientific.

I would order a 7mm implant and cut it done if need be during surgery. An 11 mm wide implant, which is the third and final size, is quite big and is only reserved for those men who want the most extreme jaw angle accentuation.

The best way to think about recovery from jaw angle implants is that it will be tougher and longer than you think. In general, most patients underestimate recovery from any type of plastic surgery and jaw angle implants are no exception. The issues are prolonged swelling and stiffness/soreness of mouth opening and chewing. One really doesn’t start to feel and look more normal for about 3 weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had jaw angle reduction surgery three months ago and I am unhappy with it. I wanted to make the thickness of my jaw angles more narrow and thought that Botox injections to the muscle would work. Instead the doctor told me that I needed bone removed instead. During surgery, the doctor cut off my entire jaw angle and I just don’t understand why? It’s make my face look too short now and I am less attractive than before. I am very sad about having this surgery.
I am only 32 years old and don’t want to live the rest of my life looking like this. I have attached some pictures and x-rays (before and after surgery) for your review. 

A: I have reviewed your case and the x-rays. What you had was a classic jaw angle reduction surgery. This is well shown on the x-rays and in your before and after photographs. Overall, I think the surgery was done adequately. One of the jaw angles has been cut off more than the other, accounting for the asymmetry in how the jaw angles look now.

For those seeking to get a narrower and less square face, this can be a good operation. One of the negative aspects to the procedure is that it makes the jaw angles blunted in addition to making it more narrow. In fact, it makes the jaw angles more narrow by virture of changing a square corner into a rounded one. That may not always be a good aesthetic trade-off. (and is what bothers you now)

In the desire to make a square face more narrow in a female, you have to distinguish between keeping the jaw angle square but making the bigonial width more narrow…or narrowing the width of the jaw angles but keeping the squareness to it. That is a very important distinction to make because achieving those looks requires two completely different approaches. The former needs to be done with Botox injections or doing a sagittal bone reduction in a flaring jaw angle (if present). The latter is done by the classic jaw angle reduction osteotomy. They both will make the lower face more narrow but the shape of the jaw angle will look different. Jaw angle reduction surgery makes the face look shorter in the back, muscle reduction or sagittal bone reduction does not create that effect.

The question now is. where do you go from here? Do you want some of the squareness to the angle back? If you do, then one may consider a thin jaw angle implant. (3 -4 mms) This will get the definition of the jaw angle and not add much width to it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’m interested in customized mandibular angle implants for enhancement and to camoflage asymmetry and a contour defect from previous corrective jaw surgeries. I’ve had several jaw surgeries in the past. I had corrective jaw surgery which involved moving the lower jaw and chin forward. This surgery did not go very well. Due to an impacted wisdom tooth on the left side, I suffered a substantial amount of bone loss and was wired shut for several weeks. I also suffered nerve damage on the left side from the nerve be badly stretched. I had a revision surgery with another surgeon who repositioned the chin to correct asymmetry and placed a lateral onlay medpor jaw implant on the left side. I would like to have the implant removed and different style implants placed on both sides of my jaw. I would like to camoflage my defect and at the same time enhance the lower angle.

A: It appears you had orthognathic surgery and suffered what we call a ‘bad split’ on one of the mandibular osteotomy sides. (this is why it is a good idea to take out the wisdom teeth six months in advance of the procedure so the bone can heal and have better bone to work with. (I have been there before) I am assuming that the left side eventually healed but it resulted in the jaw being more posteriorly positioned on that side, resulting in chin asymmetry. Then you went on to have a chin osteotomy for anterior asymmetry correction and an onlay implant over the healed but deficient side of the lateral mandible where the sagittal split went bad.

I don’t necessarily think you need a custom implant on the left side. While it certainly can be done, the cost difference to do so may not be the effort. A careful analysis of your facial photos and x-rays is first needed to determine of that is necessary. Most of the time the problems can be improved with implants that are available off-the-shelf. You will likely need a different style and size of implant for the left side than the right. One option is the Medpor Ramus jaw angle implant with an inferior ridge on the left side. That type of implant would cover both the angle and the ramus and inferior border where the old bone defect site is. That would provide 7mms of angle width with the choice of either 5mm or 10mm lowering of the inferior ridge. The best way for me to make that determination is to look at a panorex film, which I suspect you have had at least one since your last surgery.

The other issue on the left side is the removal of the old onlay implant. That is usually not very easy with these Medpor implants but possible. You just don’t want to undergo a lot of ‘destruction’ trying to remove it unless it is really necessary. Sometimes it is better to leave it and implant over top of it. But that would depend on the size and location of the current implant in place. Again, a panorex film would be critical as the implant outline will usually show on that type of x-ray.

As for the opposite right side, I think either the smaller Medpor Ramus angle implant with the inferior ridge may suffice or a Medpor RZ angle with 7mms width. I would have a better feel for that based on an x-ray analysis.

What I would recommend is to get, or find if there are old ones, a panorex and a lateral cephalometric x-ray. With these I can trace out the mandibular shape and get a better 3-D for your unique anatomy. Then we can decide whether off-the-shelf or custom jaw angle implants are needed.

Dr. Barry Eppley
Indianapolis, Indiana

Q:  Dr. Eppley, I am unhappy with what was done to my jaw angles. The procedure was done using a saw-like tool that was used to cut off bone from my jaw angles. I think they took too much bone. I don’t want to go back to exactly the way my jaw angle was before, however, I would like to get some prominence back. I think too much was shaved down and it looks too weak now. Also, both sides are uneven so my left and right  profiles do not match which just shows how much my last surgeon was lacking in skill and technique. What can be done now to fix it?

A:  Jaw angle reduction is done for prominent or flaring jaw angles which make the lower face too square. This is most commonly done in Asian populations due to their ethnically more square facial shapes. From inside the mouth, am oscillating saw is used to remove the tip of the jaw angle in an angulated bone. How much bone to remove and how steep to make the angle of the cut is a matter of intraoperative  judgment and experience.

Restoring a now too obtuse and short jaw angle can be done with jaw angle implants. Placed from inside the mouth, the implants are inserted under the muscle back over where the bone had been cut out. The implant’s size and shape, like the original bone cut, is a matter of aesthetic judgment. While the jaw angle implant’s size should be small, positioning them to correct jaw angle asymmetry requires precise and secure placement. Using a panorex x-ray before surgery, measurements can be taken to get a good idea about the differences in bone shape around the jaw angle. This can be useful to appreciate when placing the implants as both sides can not be seen at the same time.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I have a weak chin that has bothered me my whole life. I am so self-conscious that I turn away so people can not see me in profile. I also think my entire jawline is weak, it overall looks too small for the rest of my face. Can my jawline be improved with different types of implants?

A: Historically, most people think of jaw enhancement as that of the chin only. Chin implants have been around for over fifty years and have evolved today to include a wide variety of different chin styles and sizes. For horizontal jaw shortness, a chin implant can provide a simple, quick and permanent method of significant profile improvement.

Today, jaw enhancement has progressed to consider changes along the entire jawline from back to front. Besides chin implants, the use of implants to accentuate the jaw angle have become popular. Designed to increase the width of the jaw (and some designs will lower the jaw angle as well), they increase bigonial width and create a stronger and more masculine.

Chin implants are most commonly done as a stand alone facial augmentation procedure. Jaw angle implants can also be done by themselves if an adequately projecting chin already exists. For cases of an overall weak lower jaw, the combination of chin and jaw angle implants together can make for a more dramatic change in jawline appearance. This combination (the ‘jawline trifecta’) is increasingly popular for those men who have a congenitally shorter jaw or for those want to make a stronger jawline out of an otherwise normal sized one.  

Dr. Barry Eppley