Your Questions

Q: Dr. Eppley, I had a sliding genioplasty and jaw augmentation using hydroxyapatite several years ago. The jaw is asymmetric and bumpy, and the chin was moved up instead of just forward. I wanted to have the HA paste along the jaw re-contoured if possible, and the genioplasty revised to give me some more vertical height and more projection too if possible. I also have loose skin on my neck from the massive amount of swelling that I had after the procedure. If you could give me a breakdown of the procedures id be so grateful. (Jaw HA paste contouring/ revision Sliding genio / neck lift/tightening) thanks!

A: The angle of the bone cut on the sliding genioplasty obviously created a vertical shortening effect as the bone was brought forward. Moving the chin back down and out further can be done by a repeat of the sliding genioplasty. The HA granules appear to have been used to try and create a posterior jaw angle augmentation effect. HA onlay application to the bone very often creates an irregular surface contour as it heals and bone grows into it. The HA granules can not be removed per se but they can be contoured (burred) down to create a smoother contour. As for the neck, it is impossible for me to say what may be beneficial since I don’t know what your neck looks like. Real neck tightening comes only from a lower neck/jowl tuck-up. I would assume you are young so this procedure seems a bit aggressive for your age but the problem may warrant it.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, recently I had jaw augmentation and lipectomy. Its uneven and asymmetrical. Obviously nothing is perfect but I expected better. I am interested in your chin augmentations for a better jaw line as well as possible wrap around full custom augmentation. I look forward to speaking with you about these revisions. The liposuction isnt aggressive enough and the implants are sligtly off as I said before. I should have traveled to you first. I am interested in a face time consult with you. As you can see the left jaw angle is different that the right and the liposuction needs to more even and closer around the bone. Hopefully a chin implant and small revisions can accomplish a strong even jawline where the bone line is visible.  I don’t know how the doctor I went to has the credentials he has as he is satisfied with this procedure. I wish I came to see you first. I just wanted a defined jawline and facial definition not an asymmetrical nightmare.  

A: Thank you for sending your pictures and telling your surgical story. I don’t have the advantage of knowing what you looked like before surgery or exactly what implants were placed. You mentioned that you had ‘jaw augmentation’ but that can mean different things. My assumption was that you had chin and jaw angle implants placed separately (three separate implants)?? If this is so one has to realize that a smooth even jawline that connects the front and the back (chin to jaw angles) is never going to be possible as, even if the implant wings overlap, these are the thinnest sections of the implants. Thus there will always be a ‘dip’ in the middle of the jawline. Only a custom wrap around jawline implant which is made to augment the entire jawline can accomplish that effect. That is the one trade-off for having three separate implants.

However, your description of jaw augmentation may also only be that you had jaw angle implants only. Again they only come so far forward so there is going to be a drop off in the jawline as it approaches the chin. The main complication with jaw angle implants is asymmetry. It is very hard to get perfectly symmetric jaw angles with implants. Symmetric placement is difficult and most people do not have symmetric jaw angles initially. That combination leads to a high rate of jaw angle implant asymmetry.

I would need more information as to exactly what implants you have in place.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I looked through your blog but didn’t see this question so I thought I would ask you here. I know jaw augmentation has a high rate of swelling, so I wanted to ask; do you recommend someone wear a facial compression garment for say the first 4 or so days to help with this or would this not help/ be a hindrance to the healing process? Also, would taking something like Arnica montana and Bromelain be of any use in swelling/ bruising( from what I’ve read on some surgeons websites ). Thank you for your time.

A: Thank you for you inquiry about the management of swelling after any jaw augmentation/jawline implant enhancement procedure. While there may be no detailed information in my blog to date in this topic, there will be now.

Jaw augmentation can potentially cause some of the most proportionate swelling on the face after surgery. This is because it requires lifting up much of the outer portion of the masseter muscle to place the implants. Because the masseter muscle is the second largest muscle on the face (the temporalis is the largest and is more on the side of the head than on the face), any disruption of its attachments can cause some profound swelling. The amount of that swelling is partially affected by the extent of the muscle elevation and how the tissues are handled. But there is no getting around the fact that there will be some substantative muscle edema and swelling.

Knowing this in advance, steroids are given intravenously during surgery as a pharmaceutical management strategy. This is probably the most effective strategy for reducing the amount of swelling that would otherwise appear. A compressive wrap is placed after surgery for the first 18 to 24 hours and is taken down the next day. This, like steriods, is about steroid control not resolution. Any wearing of the compressive wrap beyond that time period is more for comfort and has not been proven to help swelling go down any faster. Arnica and Bromelain are homeopathic agents that are commonly touted and used after plastic surgery procedures as anti-bruising and anti-inflammatory modalities. While they are certainly harmless and inexpensive, no scientific controlled study has ever been done that provides conclusive proof of their benefit. But their lack of any side effects makes their use of, at least, some psychotherapeutic benefit.

Beyond what is done during and immediately surgery, time and healing is the only really effective agent that ultimately eliminates swelling after jaw augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a question about Kryptonite bone cement. Can it be used to build up the jawline. I was born with hemifacial microsomia and my jaw on one side is short not very full. My bite has been corrected by a jaw osteotomy previously but the overall side of the jaw is still small and too thin. Would this be a good use for this type of bone cement material? Also what would happen it is got infected after surgery?

A: Kryptonite bone cement is FDA-approved for all craniomaxillofacial bone applications whether it is as an inlay, onlay or any combination thereof. Therefore, it is appropriate  to use it as an onlay augmentative material for the mandible or any other facial bone for either reconstructive or cosmetic indications. So it could be safely used for jaw onlay augmentation.

Having 20 years experience as a craniofacial plastic surgeon with a lot of experience in biomaterials in the craniofacial region, Kryptonite has a very steep learning curve with its use. It handles completely different than every other bone cement material used in craniomaxillofacial surgery.  It would also be a challenge in getting into a site with difficult access such as the jawline. What I have learned in complex cases like yours is to first get a 3-D craniofacial model made from a CT scan. Then use that either to premake the desired implant for other synthetic materials or use it sterilized during surgery to custom make an implant intraoperatively out of Kryptonite. This will help tremendously in getting the best contour shape and in its placement.

Once  an implanted material gets infected, Kryptonite or otherwise, antibiotics will not usually solve it. The material must be removed to cure the infection. The material is simply inoculated, particularly a porous material, and you can’t get rid of the bacteria with drugs alone. They will only provide a temporary amelioration of the infection which will return as soon as the antibiotics are stopped. Clearly this is a problem to be avoided which is why I always mix in antibiotic powder with any bone cement material in the preparation process.

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