Q: Dr. Eppley, I want to get cheek implants, a sliding genioplasty and jaw angle reduction.My question is that I have just had maxilla advancement jaw surgery (LeFort 1 osteotomy) one months ago. Only the maxilla was moved forward. The mandible was not moved. How long is necessary to wait before I can come see you to get these surgery procedures done? I worry the maxilla may be banged in the surgery or after 4 weeks is this not a problem?
A: Since you just had a LeFort 1 osteotomy just four weeks ago, I would wait a full 8 weeks before doing any surgery that would involve re-entering the surgical site (cheek implants) This is not because the maxilla has any change to be displaced. (it is undoubtably rigidly secured into place with plates and screws) but because you want all the swelling to get out of the cheeks so you have a good idea when placing cheek implants so that the style and size of the implants could be best judged. As it relates to the mandibular procedures (sliding genioplasty and jaw angle reduction) the previous LeFort 1 osteotomy has no impact on their execution and vice versa. But waiting until all facial swelling has resolved is still worthy of the wait.
Dr. Barry Eppley
Q: Dr. Eppley, I’m wanting to have jaw angle reduction to make the face slimmer.
1.Is it correct that if the jaw angles get cut; then the periosteum that covers the jaw angles will also get detached or cut, correct?
2. The “standard “ jaw reduction surgery would ensure that the periosteum is intact to the jaw bone throughout the procedure. Not to cut the jaw angles which will also result in loss of shape and bone support. Therefore it is best to do a sagittal reduction to make the jaw slimmer?
3. For the sagittal reduction, does it mean that the periosteum does not get detached? I read that a standard procedure would be to keep the periosteum intact and have a sagittal reduction, not cut the jaw angles ? But I don’t understand why the periosteum does not get detached in a sagittal reduction?)
A: The periosteum must be elevated (detached) from the bone in any jaw angle (mandibular ramus) procedure. That is not what is important in preventing soft tissue sag after jaw reduction surgery. The relevant issue is the preservation of the bone angle shape. A traditional jaw angle reduction obliquely removes the full thickness of the angle where various ligaments attach. It will dramatically make the width of the angle less but do so at the loss of angular shape and potentially soft tissue support. The sagittal reduction method preserves the angular shape and soft tissue support although the width reduction will be less.
Either jaw angle reduction technique has its place. It depends on the natural jaw angle shape and thickness of each patien and what one is aesthetically trying to achieve.
Dr. Barry Eppley
Q: Dr. Eppley, I am looking for a surgeon who has proper training to do “mandible angle reduction”surgery. (This is a form of plastic surgery, aesthetic not reconstructive, to reduce the square jaw angles for patients who do not have jaw angle deformities but just wish to reduce square jaw angles.) However, I am not sure what training a doctor should have to perform this type of surgery.
a) Is it enough for a plastic surgeon to attend a 3 day forum for “ Surgical-Orthodontic Approach to Dentofacial Deformity”, to perform “mandible angle reduction”and cut people’s square jaw angle bones?
b) Would attending a 3 day forum on “Surgical 0rthodontic Approach to Dentofacial Deformity” be RELEVANT to equip a plastic surgeon to perform “mandible jaw angle reduction?
c) I cannot find information on line about “Orthodontic Approach to Dentofacial Deformity” so I have no knowledge/understanding. What is this about? Orthodontic is a branch of dentistry so I cannot quite see how this 3 day forum relates to doing mandible jaw angle reduction.
d) What training should a plastic surgeon have, which would be relevant or adequate to perform “ mandible jaw angle reduction” ?
A: The question you are asking about what qualifies a surgeon to perform jaw angle reduction surgery is not a simple one as that training/experience could be gathered from a variety of different experiences. Any surgeon that would perform this procedure would be trained and very experienced in facial bone surgery. This could come from a plastic surgeon with craniofacial surgery training or an oral and maxillofacial surgeon with good orthognathic surgery experience. Jaw angle reduction surgery, while simple in concept, is technically challenging as is all surgery of the mandibular ramus due to the limitations of surgical access.
I can speak about the forum you have mentioned in the context of your question since I have not seen or attended the program. Although that is clearly a course in orthognathic surgery of which aesthetic jaw angle reduction would not typically be a part of that course curriculum.
Dr. Barry Eppley
Q: Dr. Eppley, I am a woman with square jaw who just wants to have her angles rounded off, nothing extreme…so far, the people I’ve seen who have had jaw angle reduction/resection were left with no angles at all and I found it unnatural and unattractive. I saw a professor who talked to me about bone decortication, removing a little bit the angles without touching the bone or touching the muscle and that it can be done under local anesthesia with little risks and would give a natural result. But he said that asymmetries are common with that type of method. Is that all correct?
A: Jaw angle reduction/recontouring can be done by two basic methods, bicortical (amputation) or monocortical. (decortication) While the historic and still most commonly used technique is bicortical removal, you are correct in that such amount of bone removal can make the jaw angle ‘hollow’ and create a soft tissue sag or indentation over the jaw angles. For many patients, a monocortical approach may be better as it lessens jaw angle width but without losing jaw angle shape. The best candidates for this type of jaw angle reduction surgery are those that have radiographic comfirmation of an angle flare that sticks out beyond the external oblique ridge of the mandibular ramus. This makes it technically possible to reduce the jaw angle flare with the instruments that are available to do it.
But no jaw angle recontouring method can really be effectively done under local anesthesia. (nor can I imagine who would want to) It is necessary to lift the masseter muscle off the bone to provide visualization for the bone reduction. Any method of jaw angle manipulation (augmentation or reduction) run the risk of asymmetry because they can not be seen as a ‘pair’ surgically and most people do not have perfect jaw angle symmetry beforehand.
Dr. Barry Eppley
Q: Dr. Eppley, I went to Asia and had mandible angle jaw reduction. Now my face looks deformed with a protruding bulging area as well as indented area on my jaw line. Please can you have a look at my attached images. I now have CT scans. Please let me know what you think has happened. I need help and just don’t understand what has happened. The surgeon in Asia was suppose to only cut the posterior jaw angles off to get rid of the square jaws. However, something has gone wrong and I really need help. Please see my CT scans, I would really appreciate you giving me an idea of what might have happened. (I may need some kind of jaw implants for a corrective surgery. However, it is alright with me if you are not happy to give me a corrective surgery as I understand most doctors don’t like doing corrective surgeries. ) I’m trying to find out what might have happened from my previous surgery /jaw angle reduction, and I don’t understand the CT scan. ) I would appreciate any help as I really need help.
A: What happened to your jawline is very simple. They cut off the angles completely. The bump you see on the jawline is the front end of the cut where it is not smooth with the rest of the jawline. The indented area is the loss of bone support for the soft tissues from the removal of the jaw angles. You are a classic example of why the jaw angle reduction with an amputation technique is usually not a good operation. It would be better to have a lateral shave of the jaw angles so the bony support is not completely lost. Restoration will require some form of a jaw angle implant that provides vertical length but no width.
Dr. Barry Eppley
Q: Dr. Eppley, I have questions about jaw angle reduction and temporal implants. Here’s a list of my questions I want to ask:
1. My jaw is still growing and i have braces, will this affect anything? What possible complications can there be? I’m willing to take all the risks and complications. ( i am getting the braces removed soon)
2. If my jaw angle is vertically reduced to make its location higher, will this make it higher from the front view too? Can this be an possible result? By higher i mean close to the ear.
3. Is there any implant to make my head larger or my forehead larger? Since my face is long, i want to make it more proportionate. I have been reading about the temporalis muscle, any implant/augmentation surgery for that
4.what is the difference between having the jaw shaved with a ear incision, and inside mouth incision? Recovery time? Results? Damage? Risks?
5. Here comes the important part… How long is the recovery time? For the ear incision & inside mouth incision? Is there any massage or laser treaments i can take to dramatically reduce the swelling so i can look ‘normal’ after a week of recovery?( i’m willing to pay a lot for any treatments that’ll help ) please include the implant part as well!
6. is it possible to do implant and jaw reduction surgery together? If so how much time will it take and what risks are there?
A: In answer to your questions:
1) Having braces and undergoing orthodontic treatment has no impact on any type of jaw angle surgery.
2) The traditional method of jaw angle reduction surgery does exactly what you are describing. It removes the jaw angle so that the most posterior part of the jaw angle is at the same level as the earlobe. It is important to understand that is so doing the jaw angle will no longer have a square form but a more rounded or sloped angulation.
3) Forehead and mid-temporal augmentation can be done to achieve a larger more pronounced forehead and increase the bitemporal distance for a wider head as judged by its width above the ears.
4) The jaw angle can be reduced by two different surgical approaches. (incisions) The intraoral method is the historic and most common method still used but it does pose challenges for angling the bone cut in an ideal and symmetric manner. The external approach uses an incision behind the ear or just below the ear and provides a much better angle for the bone cut and a quicker recovery (by staying out of the mouth) but runs the risk of causing temporary or permanent facial nerve injury. (that risk is low but is not zero)
5) There is nothing a patient can do to expedite the recovery process which is largely about who long it takes the swelling to go away before one looks human (7 to 10 days) and for its complete resolution. (4 to 6 weeks)
6) It would be common to combine any number of aesthetic craniofacial procedures such as jaw angle reduction and temporal augmentation. The risks of such surgeries, besides infection, are largely aesthetic…symmetry, over/under correction of the desired goals.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in jaw angle reduction surgery. My problem is that my jaw line is low which gives me a rectangular/long face look. But honestly I don’t really mind that… I prefer having a softer angle. Mine is really low. If it was higher it would be good. But I’m wondering if you can actually do this surgery in several appointments? Like each time cut/thin off a tiny bit of the bone, so that it’s safer and faster… Honestly I’m scared that the results will be too drastic.
A: On a practical basis, you would really on go through a single jaw angle reduction procedure….and be certain that it is not too radically done. It is possible to do it in stages, and there is nothing wrong with that approach (and might end up that way anyway with a conservative reduction and if you like the improvement and want more), but most patients would only want one surgery. But doing smaller amounts does not result in a faster recovery…as the same dissection is needed to reach the jaw angles. The amount of jaw angle bone removal has nothing to do with the length of the recovery period.
The key to a successful jaw angle reduction in is too simply not over do it. (remove too much bone at too steep of an angle) It is somewhat easier to do more than to add back jaw angle height that has been removed.
Dr. Barry Eppley
Q: Dr. Eppley, My problem is that my jaw line is low which gives me a rectangular/long face look. But honestly I don’t really mind that… I prefer having a softer angle. Mine is really low. If it was higher it would be good. But I’m wondering if you can actually do this surgery in several appointments? Like each time cut/thin off a tiny bit of the bone, so that it’s safer and faster… Honestly i’m scared that the results will be too drastic.
A: On a practical basis, you would really only go through a single jaw angle reduction procedure….and be certain that it is not too radically done. It is possible to do it in stages, and there is nothing wrong with that approach (and might end up that way anyway with a conservative reduction and if you like the improvement and want more), but most patients would only want one surgery. But the key in jaw angle reduction in general is too simply not over do it. It is somewhat easier to do more than to add back. Whether the jaw angle reduction procedure takes off a little or a lot, its safety, time to do the surgery and recovery would still be the same.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in jaw angle implants but for an unusual reason compared to most people who have jaw angle implant surgery. I naturally had well defined and square jaw angle which are not considered aesthetically desirable in Asians. I had jaw angle reduction surgery which I came to now realize is the old style amputation of the jaw angle bone. This has resulted in the soft tissue which has fallen and moved forward and therefore the frontal view of my face is now heavier than before. A CT scan also showed that the angles are not even and or the same on both sides. In addition, the angle is a lot steeper than before. Overall, the face is considerably narrower than before as the bone has been cut off. However, the face does not look better as I have a jowl (premature aging) due to this soft tissue which has fallen. Now, I am thinking that I would like some of that angle back as my new jaw has no definition. My questions about this potential surgery are:
1. I’d like to have a bit of an angle back to give the face definition. However, I don’t want the face wider. (I have a short face, and fear jaw implants will make my face rounder.) What would you do to obtain this?
2. What is the risk of any complications such as infection?
3. What material is the custom jaw implant be made of? I heard some say it’s made of acrylic PMMA? Is this safe? What material is the safest?
4. How many years can I keep this jaw implant?
5. Is it possible that I send you a CT scan in order for you to make a custom jaw angle implant? How long will it take for you to make this custom implant?
In addition, I have kept the jaw bones which were cut off.
A: In answer to your ‘reconstructive’ jaw angle implants questions:
1) The jaw angles can be replaced by implants that restore the angular shape (in the dimensions of height and length) but that adds no width at all and stays in line with your current jaw width.
2) While infection is always a risk with any implant in the body, I have only ever seen one and that was with a porous implant material. Infection in jaw angle implants, like most facial implants, is very uncommon.
3) I prefer silicone material for all facial implants when possible. This is because it is easy to insert (and remove if necessary), has the lowest risk of infection of any implant material, and is the least expensive to manufacture particularly when it comes to custom made implants. (PMMA implants can also be custom made using a skull model made from your CT scan and hand fashioned)
4) These implants should be permanent, will never break down or need to be replaced. (provided the desired aesthetic objective is achieved)
5) I would need to see the CT scan to see if it is adequate for custom implant manufacture. It would need to be a 3D CT scan done in high resolution.
The other very unique possibility since you still have the cut off pieces of jaw angles is to use them to manufacture the implants by designing directly off of them. I have never done that before but then no one has ever still had the their removed bone specimens.
Dr. Barry Eppley
Q: Dr. Eppley, I had jaw angle reduction surgery last year. I told the surgeon I wanted my jaw slightly slimmer, but I said I wanted to keep the same shape and definition of my jaw. However, there does not seem to be any difference in the width of my jaw, but unfortunately my jaw angle slopes now, whereas before I had a nice defined jaw angle. I didn’t want to lose the jaw angle, just some of the width. From the front I look basically the same, although I had been hoping for a slightly slimmer lower face, but from the side and 3/4 view of my face, I have lost my nice jaw angle definition, which was what I wanted to keep. Was what I was requesting impossible? Thank you in advance for any insight you can provide.
A: I can not tell you whether what you were asking was impossible as I have no idea what your face looked like before your surgery or looked like now. But I can give you some insight about jaw angle reduction. There are two basic techniques and they are done differently. Width reduction of the jaw angle is done by removing the outer cortex of the bone, either by a split osteotomy or burring reduction. Amputation of the jaw angle removes the tip of it, which make reduce width but will also shorten it vertically as well. What technique you had done is unknown to me but it sounds from the result that it may have been more of an amputation approach.
Whatever the jaw angle reduction technique that is decided on before surgery, it is first necessary to see an x-ray of the jaw angles to see how much flare they have and its thickness. That information will help determine if the procedure, regardless of the proper technique, actually has a chance to make a visible difference. This would be of particular importance in the width reduction jaw angle approach as the thickness of the bone determines whether enough can be removed to justify the effort.
Dr. Barry Eppley
Q: Dr. Eppley, I underwent mandible angle and cheekbone reduction surgery over a year ago. I am disappointed with the changes as it has feminized my previously masculine face. I find that the angle reduction from my jaw is unnaturally high and much too straight to be considered normal. What options could I consider to replace the previous bony structure? Another issue that I am faced with is substantial mid to low face sagging. Several areas seem to be affected such as the infra-orbital muscle (clearly visible, elevated on cheekbone), nasolabial folds, and soft tissue isolation (sides of mouth, fat cheek look). Could you explain the causes of these irregularities and possible procedures that I could undertake?
A: I have seen a few cases just like yours where the jaw angles have been completely amputated. The angular shape and the vertical height of the ramus of the mandible can be restored by jaw implant augmentation. But the implant shape can not be a standard jaw angle implant. it needs to be shaped to just have a vertical augmentation only that has an oblique superior shape to match the oblique cut. That can be done by either using one of the custom jaw angle implant shapes that I have previously used or have one made off of a 3D CT scan.
As for the other facial changes those are obviously a result of the cheekbone reduction. I am going to assume that this procedure was done intramurally with n obliquely oriented osteotomy of the zygomatic body and a posterior osteotomy of the zygomatic arch. That has caused loss of support of the surrounding cheek tissues which not sag creating an orbicular is muscle edge show, deepening of the nasolabial folds and sagging in the submalar area. Like the jaw angle issue, adding back some skeletal support would seem like a logical approach. That effectiveness, however, is not as clear as it would be in the jaw angle area.
Dr. Barry Eppley
Q: Dr. Eppley, My surgeon indicated that he wants to perform a mandibular osteoplasty to reduce the squareness of my angles; this is why he would need to use screws. He told me that the bone is so hard to reach that he doesn’t use the angles osteotomy, he doesn’t know how to do that. He is a maxillofacial surgeon and not a facial feminization surgeon.
Are you aware of the mandibular osteoplasty surgery? Is that appropriate to reduce mandibular angles? Does that give a more natural result to the angles? One that causes less asymmetry or sagging skin? Is a maxillofacial surgeon appropriate for that type of surgery? (purely aesthetic as I have no functional problems)
A: The term, mandibular osteoplasty, is a generic term (means jaw bone reshaping) that does not imply any specifics about the surgical technique. You would have to ask him to draw exactly what this technique is to understand what is being proposed. However, I suspect he is talking about doing a sagittal split ramus osteotomy as this would be the only jaw angle procedure in which screws would be used to fix the bone back together. I do not see any reason or indication in this approach for what you are trying to achieve aesthetically. I suspect you are correct in that this particular maxillofacial surgeon is taking a functional rather than an aesthetic approach to your concerns.
Dr. Barry Eppley
Q: Dr. Eppley, I went to see a maxillofacial surgeon to get jaw reduction (my jaw is too square and X rays show that my angles do stick out). He told me that he needed to do a small resection of the angles (osteotomy) because my angles were too square to burr them. and with the burring technique, only 2 or 3mm could be burred which would barely show. Is it possible to round off the angles with the osteotomy technique? or will it be a straight cut leaving the angles straight looking cut and unnatural? is it possible to preserve some angles with that technique? Also, what really surprised me is that he said that since the bone is so far and hard to get to due to the muscles, he might need to put some screws; I did not understand why. I thought that screws were used to put bones back into a new position; which would not be the case with angles osteotomy? I am confused. Thank you for your answers.
A: I can only speak for what I do, I can not explain what your surgeon said or their technique. When you cut off the angles, no matter how small, there will be a rounding effect created. Burring in the jaw angle area can be difficult because of the surgical access. Therefore, I choose to use a reciprocating saw and perform an outer table ostectomy, which thins the bone but preserves most of the angle’s shape. I have never used screws for this technique nor can I envision why they would be needed.
Dr. Barry Eppley
Q: Dr. Eppley, I can not seem to find any surgeon who performs shaving or burring of the jaw angles! They all do osteotomies of the angles and the results look awful and unnatural. Would you know why most facial feminization surgeons do not shave the jawline? They cut off the bone (angle resection) instead. I am wondering if it is a typical technique used by FFS surgeons? Because they operate men to become women so they go extreme. I am already a woman and just want a softer jaw. Would you know how many mm can be shaved off the angles? and how many mm off the jaw close to the chin? maybe it is so limited that they rather cut so they can remove 1 to 2 cms, which to me, seems a lot on a face. I wonder if I should go to a maxillofacial surgeon instead?
A: My best answer is that is just a lack of experience and knowing the different options that can be done. Also total jaw angle removal is easier to technically perform than outer cortical reduction with jaw angle preservation. It is important to apply the right operation to the patient rather than just the one operation you know to every patient. Most likely you can get about 5mms reduced from each jaw angle reduction, tapering to about 3mms behind the mental nerve.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 21 year old guy with a big jaw and a long chin. Also my jaw line is low which gives me a long face. What’s the best and the safest thing for me to do? Should I go for a jaw line reduction surgery and a chin reduction surgery as well? Are they safe? I have attached some pictures of my jaw from different angles.
A: Thank you for sending your pictures. You do have a most unusual pattern of jaw hypertrophy that I have ever seen with excessive horizontal chin projection and jaw angle protrusion. It would be very help to see some x-rays (even a panorex would be useful) to confirm that the bulges at the jaw angles are primarily bone and not masseteric muscle hypertrophy. But let us assume that these are all bony protrusions, they could be reduced through intraoral approaches by burring reduction of the chin projection and an osteotomy/saw reduction of the lateral jaw angle protrusions. These are not only safe but the only jaw surgery options you have for their reduction. If the vertical length of the chin is felt to be too long, then a vertical reduction osteotomy could be performed by the horizontal burring reduction. But it would be important to manage the then excessive chin soft tissues that would result from the reduction of the bony support. I would performed suture suspension of the soft tissues to the reduced chin size.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in jaw angle reduction surgery but I am worried about the risk of asymmetries. In most before and after pictures that I have seen, I do notice asymmetries… one side of the jaw is thinner than the other. Why is that happening since X rays are being taken before surgery? Is it difficult to see where to shave during surgery? Is that a common risk? I also have seen some patients complaining about bumps and dips on the jawline (bony irregularities), why does that happen? Is that a common risk? Thank you so much.
A: As you have observed with excisional jaw angle reduction surgery, symmetry can be difficult to achieve. Having an x-ray before surgery is not helpful in executing the actual procedure. Doing the procedure inside the tight confines inside the mouth is quite different than making drawings on an x-ray. It may help estimate how much bone one wants to remove, but during surgery there is no way to see both sides simultaneously and no way to know if one side matches the other. In essence, excisional jaw angle reduction surgery is a guess on each side of the angle of the bone cut and how much bone is being removed. This problem can be magnified if the patient already has some existing asymmetry in the shape of the jaw angles. Converselly, burring or shaving the jaw angle is different. Because you are keeping the existing outline of the jaw angle bone and merely making it thinner, the risk of irregularities/asymmetries is dramatically reduced.
Dr. Barry Eppley
Q: Dr. Eppley, I had read online some of your comments about jawline reduction for square faces. So far, I have only seen jawlines that look like they have been cut and it looks unnatural and too short from the sides, and also, from the sides it shows no angles at all. I am therefore hesitating to do this surgery. Asymmetries (I wonder how that can happen since X rays are being done) and sagging skin. I am just looking for the angles (the whole jawline?) to be rounded off just enough so my face doesn’t look square; I have done Botox but it created some jowls and my face got hollow and it only reduced the masseter muscle, I had a hard time smiling too and the muscle would bulge when I ate.
What should I do to have a more feminine, natural, softer jawline? I want to avoid sagging skin too (I’m 42 years-old); will shaving only a bit would avoid this? Is it worth it then?
A: The key to jaw angle reduction is understanding whether jaw angle ostectomy (amputation) is needed or whether jaw angle outer corticotomy (width slimming) is needed. Unfortunately, the historic concept of jaw angle amputation persists and is commonly used, whether that is what the patient really needs or not. That is why you see faces, as you have described, that have had jaw angle reduction and look like they have no angles at all. Your jaw angles would need to be reduced using removal of the outer cortex only, thus reducing width but not losing the support of the bony angle completely. Your ‘failure’ with Botox injections indicates that the muscle is not the primary reason for the excessive contour. Whether reducing the outer cortex of the jaw angles is worthwhile depends on how much the bone is contributing to the flair that you have. The Botox treatments you had is a favorable indicator but it would be conclusively helpful knowing what the bone looks like as well. Therefore a simple AP facial/jaw x-ray view would be most helpful to decide either way if this procedure would be helpful.
Dr. Barry Eppley
Q: Dr. Eppley, I’m interested in getting a jaw reduction surgery done. I am a 25- yr old female with a jawline significantly wider than cheek bones area. My jawline alone is wider, adding to that strongly developed mandibular muscles makes my lower face evidently out of proportion.
1) Do I need anything additional done besides the jaw reduction surgery?
2) For how many days would I ave to remain hospitalized?
3) I live out of state, so how could the follow up appointments happen?
4) how many follow up examinations does Dr Eppley usually do? And what is their time frame?
5) what is the approximate cost I would be looking at (including hospital stay)?
A: In answer to your questions:
- I would need to see some pictures of your face to determine what, if anything, else make be helpful in achieving your goal of a more narrow lower facial width.
- This type of facial surgery is done as an outpatient procedure. There is no reason to be hospitalized for jaw angle/jawline reduction surgery.
- As a general rule, my out of state/country patients follow-up by e-mail, phone or Skype. There are no regularly scheduled in-person follow-up examinations needed. When it comes ti changing appearance what matters is how things look and that can be discerned with modern technology from afar.
- as per #3 above
- I will have my assistant pass along that information later today or tomorrow. Although be aware that this is a cost estimate for a procedure on a face that I have not yet seen.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 25 old year guy and I am really not satisfied with my looks. I am looking to improve upon my face for a more youthful look .I know it’s not wise to compare yourself to others as everyone’s face is unique but I think the most distracting feature of my face is a very big and wide lower face (mandible) that makes my face chubby and more old looking. The last time I inquired you about an outer cortex osteotomy for as such the same problem and you requested my pictures so I did attach them. Now I would be really grateful if you clarify me my following doubts:
1. Is it possible to reduce my lower jaw width and angle to make my face more slimmer and proportionate?
2. If yes, how much is it possible to reduce the bigonial distance and achieve a more ovoid looking face (Front view) in my case?
3. Would chin augmentation be helpful to achieve the same?
4. I also want to have a tip rhinoplasty that would give my nose tip more definition and sharpness. Again, how much is it possible to achieve a nose like the one in the model pictures I have attached?
5. Please suggest any additional improvements in case you notice that would be required for a more youthful appeareance such as brows,cheeks or any other.
A: In answer to your questions:
1) There is not a really good procedure to make your entire lower face more narrow. Even if one could do a lateral corticotomy (remove the outer layer of the lower jaw bone) that would just not make enough of a difference in your face.
2) Certainly the jaw angles can be removed but whether that would make a very visible difference is uncertain. Some of your facial width is soft tissue and can not be reduced. The best way to answer whether this procedyure would be worth it is frontal cephalometric x-ray or facial film to look at how much flare the angles have. If it is significant then it may be worthwhile.
3) Vertical chin lengthening is, by far, a more practical approach to facial lengthening (and narrowing) for you given the more square facial shape that you have.
4) A tip rhinoplasty will definitely help narrow your nose but trying to achieve the very slim noses in the pictures you have sent is unrealistic. You will likely end up halfway between where you are now and those type of results.
5) Some soft tissue (fat reduction) would also be helpful, removing part of the buccal fart pad and thinning out the fat outside of the corners of the mouth.
I would think that a vertical lengthening chin osteotomy, tip rhinoplasty and buccal lipectomy with perioral liposuction would be the three procedures that I would recommend that could make the greatest difference in your facial shape/appearance.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 28 year old woman with slim build. I have been unhappy with my facial structure and feel that the lower half is “heavy” and undefined while from cheekbones up, it is narrow and flat. I am considering buccal fat removal to even out my lower cheek/ jaw. I wan a slimmer face as well as a more delicate mouth and rounder forehead. A more heart-shaped face, as opposed to my triangular one (bottom heavy) What is your opinion? Thank you!
A: This is what I had thought your concerns were. From a lower face standpoint, what makes your face heavy is the wide lower jaw/masseter muscles. This is due to your ethnicity as you know. There is no type of fat removal, buccal lipectomy or otherwise, that is going to make that change as the problem is not one of fat. It is due to your musculoskeletal structure. Typical options include repeated Botox injections to the masseter muscle to cause it to shrink/atrophy and/or bony jaw angle/inferior border mandibular reduction. There are advantages and disadvantages to either approach which is demonstrated in their injectable (non-surgical) vs surgical approach. From a forehead standpoint, a rounder and more convex forehead is achieved through an augmentation material using a hydroxyapatite cement to build it out. (forehead augmentation) This is done through an open scalp approach.
When these procedure are combined (upper and lower face), this is how a truly effective facial shape change can be achieved.
Dr. Barry Eppley
Q: Dr. Eppley, I am an Asian female with prominent jaw angle. I would like them reduced to be more angular. They are also causing pain to my neck and shoulders. I want to make them more narrow so my neck isn’t as tight.
A: Thank you for your inquiry and sending your pictures. I can clearly see your flared jaw angles which seem not to fit the rest of your face. I have not heard of prominent jaw angles causing neck discomfort and tightness but you would know best how it feels on you. The jaw angles are enveloped by the pteryomassteric muscles and not any neck muscles per se so I can not speak for how successful they would be in reducing your neck and shoulder pain. Your jaw angles could be reduced by a sagittal saw reduction technique to narrow them as opposed to a complete transection technique of the entire angle. This is my preferred method which I think gives a better aesthetic result.
Dr. Barry Eppley
Q: Dr. Eppley, I am Asian and am interested in getting my jaw angles reduced. They make my lower face look too wide. How risky is the surgical reduction? And how long is the down time? Is it possible for me to undergo the procedure during spring break (2-3 weeks)?
A: This is not a procedure that I would consider risky. It is a cosmetic procedure that is about reducing the width and shape of the jaw angle. That being said, it does require the masseter muscle to be lifted off of the bone to do the procedure so there will be some significant swelling afterwards. The procedure is done by either burring down the width of the jaw angle (outer table reduction) or actually removing the jaw angle by an osteotomy. It takes about 3 weeks for most of the swelling to go down after this kind of facial bone surgery and about another month or so to see the lower facial width reduction benefits of having the operation. I tell patients that it takes 3 months to see the final results after jaw angle reduction surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I desire a more womanly face. My face is very big and square and is way too masculine looking. I am not sure if my jaw angle needs reducing or if Botox injections will suffice. Can you please advise? I have attached some pictures for you to see my big square face.
A: A square face, by definition, is when the lower jaw width is just as wide as that of the cheekbones. The width of the jaw angle area plays a major role in creating the horizontal dimension of the lower face in the frontal view. The width of the back part of the jaw (jaw angles) is created by three anatomic components; the thickness or flare of the jaw angle bone, the thickness and volume of the masseter muscle and the flare of the jaw from the front (chin) to the back. (posterior border of the ramus) Only the thickness of the masseter muscle by Botox injections and the flare of the jaw angle (ostectomy or jaw angle reduction) can be reduced. The key question is which one of these two is making the greatest contribution to the width of your lower face. While I suspect it is more bony than muscle by your pictures, it is important to make the right diagnosis. I would recommend getting some simple x-rays (frontal, side and submental plain x-rays) where the bony anatomy will be very apparent. A frontal and lateral cephalometric film (orthodontic type x-rays) with a panorex will also suffice for making this diagnosis.
Dr. Barry Eppley
Q: I am interested to find out if you could help me to reduce my facial assymetry. What would you actually perform as I am not able to even guess that, but it seems that my halves are different in jaw and forehead shape. I want to make my face more symmetrical and I want to reduce and minimize the difference of my jaw and forehead. Please advise what kind of procedure do you recommend and what would be the estimated cost. Attached is the photo so you can see and assess the treatment.
A: In looking at your frontal view photograph, I see four isses that are making your face asymmetrical. The first is the difference in the sdie of the jaw angles between the two sides. The right is bigger than the left. That could be addressed by either a right jaw angle reduction or left jaw angle augmentation depending upon which side you like better. Secondly, there also appears to be left cheek deficiency which is less prominent than the right. That would be compatible with the left side of your face being smaller than the right. That could be improved by a left cheek implant. Thirdly, the right upper eyelid has more skin which hangs down onto the lashline. That could be removed by an upper eyelid blepharoplasty. Lastly, your nose is deviated towards the left side with a broader tip. That could be improved by a rhinoplasty. I think the combination of these four procedures would go a long way to improving your facial asymmetry.
Dr. Barry Eppley
Q: I am trying to make my face symmetrical. My jaw is not aligned, making my mouth and smile crooked and my nose is wide with a pronounced bump. I have attached some pictures for you to evaluate, image, and give me recommendations as to what to do. Thanks!
A: An analysis of your pictures shows that you do have a deviated nose with a hump and a wide tip. But in addition, you have left facial hypertrophy. This is the origin of why you feel that your jaw and smile is crooked. The left side of your face, from the orbit down to the jaw angle is bigger and wider. This creates your facial imbalance/crookedness. I have done some imaging of your rhinoplasty, with and with adjustment of the left facial enlargement. In facial asymmetry it is always a question as to whether to build up the smaller side or reduce the bigger side. In your case, I think it is better to try and make the larger side smaller through cheekbone and jaw angle reduction. This is shown in your rhinoplasty front view imaging, both with and without it being done. From a side view, I have also added a small chin augmentation as your profile shows some mild horizontal chin deficiency.
I think the combination of rhinoplasty, cheekbone and jaw angle reduction and chin augmentation can make for a more symmetrical and balanced face. This will not change the asymmetry in your smile as that is soft tissue-based and can not be adjusted like the underlying harder facial structures.
Dr. Barry Eppley
Q: I am Korean and I would like to have more of an oval face shape. My face seems too wide and I would like a narrower lower half of my face that looks less puffy and flabby. I am thinking that maybe jaw angle reduction nd facial liposuction would be what I need. Here are some pictures for you to see what my face looks like.
A: Thank you for sending your pictures. It appears that your desire is to narrow the lower third of your face, which is most affected by the shape of your jaw located at the angle area. The consideration of a jaw angle reduction is reasonable, it is a question of how much reduction can it achieve. That question is best answered by knowing how much the bony jaw angle is actually contributing to the fullness in that area. While it clearly makes some contribution, particularly with your ethnicity, the question is whether it is enough to make it worthy of reducing it. That question can be answered by a simple dental films, a panorex and a lateral cephalometric x-ray. They will show the exact amount of flare at the angle as well as the thickness of the bone. That information is crucial in determining whether jaw angle reduction can be justified.
Facial liposuction will make but a very minor contribution to any facial narrowing effect. I can see in your pictures the value of submental/neck and lateral facial liposuction as a possible complement to jaw angle narrowing.
From a loose flabby skin standpoint, only some type of skin tightening procedure (e.g., jowl tuck-up) would be of benefit and you seem too young for that effort at this time.
Dr. Barry Eppley
Q: I have a very strong square-shaped masculine jawline. I am not dissatisfied with my chin, but I would like to reduce the sides of my jawline, to make my face appear more oval and feminine. Does Dr Eppley do this kind of surgery? I have heard of it referred to as jaw shaving, and it seems to be popular among Asian women. I am Caucasian and I would like to reduce my jawline, not my chin. My jawline makes me look too masculine and I don’t like it.
A: One of the main reasons a jawline can look too square is at the jaw angle prominences. How much the jaw angles flare and how square the angle is has a big impact on the arched shape of the lower jaw which frames the entire lower face.
Jaw angle reduction is a procedure where the shape of the jaw angle is changed. By removing the end of the jaw angle, this area becomes more blunted or rounded. This is done through incisions inside the mouth behind the molar teeth. Using the same surgical access and instruments used to cut the lower jaw and bring it forward, jaw angle reduction is simpler and quicker to perform. There is also no risk to injury of the mandibular nerve or risk of bone healing problems as the bone is not actually split or fractured. Rather a piece of the edge of the bone is removed.
While jaw angle reduction is fairly easy to perform, one must avoid taking away too much of the jaw angle. Over resection of the jaw angle can lead to an unflattering ‘deflation’ of the angle and potential soft tissue sag. The other focus during the procedure is to make both sides evenly reduced. That seems easy but when you are working in the restricted space inside the mouth, asymmetry in resection can easily occur.
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
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
Q: Hi, I’m an Asian female in my late 20s. Over recent years, my jaws have become really prominent, making me look somewhat masculine and heavy. In ooking for a way to reduce the angle of my jaw, I found the masseter reduction technique with botox injections on the internet. Since I don’t want to change my bone structure, I am considering Botox as a solution. My only concern is how much the cost would be. Could you please let me know the range of cost? Thank you so much!
A: There are two options for prominent jaw angle reduction, surgical jaw angle bone reduction and pharmacologic masseter muscle shrinking. There are advantages and disadvantages to each approach. Which is better for any patient depends on their bone and muscle anatomy and what type of result and effort that one wants to go through.
Botox injections, in my Indianapolis plastci surgery experience, can be an effective masseter muscle reduction method. My protocol is 50 unit injections (25 units per side) into the muscle at the angle done every four months for one year. After three injection sessions, some permanent muscle reduction will be seen. Whether maintenance injections are needed is determined on an individual basis. Cost can be determined by knowing what the provider charges per unit and simply do the math. In general, the costs are around $750 per injection session.