Your Questions
Your Questions
Q: Dr. Eppley, I am interested in jaw asymmetry correction. I was referred to you by a friend and I would like to consult you over my concern. I have a slightly asymmetrical face with a swelling on the right side of my face. Based on the scan my right mandible is longer than the left side while it is more bended (curved) than left as well. To me the chin misalignment is not a big issue and doesn’t have that much impact on my look but rather the swelling on my right side of face is very noticeable and unpleasant. So my main concern is just getting rid of the swelling on the prominent side with the least manipulation on my face. Please note that I am not looking for a perfect face. More of a normal face is what I am asking for. I was wondering what options I have here to just get rid of swelling?
A: Thank you for your inquiry and sending your picture. What you refer to as right jawline swelling is not really swelling. This is reflection of your lower jaw asymmetry due to how it developed. As you appear to have had a CT scan it shows that the right jawbone is bigger and longer than that of the left side. This will also include the overlying soft tissues as well. In essence your entire lower jaw is shifted during development of which also consist of chin asymmetry and a left jawline/facial ‘shortness’.
It would be helpful to see the CT scan and hopefully it was a 3D type. But having seen many such jaw asymmetries before, the treatment approach is fairly straightforward. In an ideal world I wish just reducing the larger jaw on the right side would straighten out your face and give it substantial better symmetry. But this is unlikely to happen by itself. The reason is that you can not reduce the larger bone enough to make a big difference. (there are teeth and nerves in the bone so that is a limiting factor as to how much bone can be reduced) In addition it is not possible to reduce any of the thickness of the overlying soft tissues as it contains muscle and branches of the facial nerve.
For these reasons this is why many jaw asymmetry corrections must employ a ‘triple point’ approach. This means all three points of the jaw (chin and two jaw angles) are treated. Reducing the right jawline, straightening the chin and augmenting the left jaw angle provides the best method of jaw asymmetry correction. Even with this approach perfect lower facial symmetry is not usually possible. But it is usually the best approach to mask the lower facial disproportion which now exists.
In short, you have three options:
- Right jawbone reduction with the understanding that it will only produce a modest improvement,
- Right jawbone reduction and left jaw angle augmentation since you have stated that you are not bothered by the chin asymmetry, and
- Right jawbone reduction, left jaw angle augmentation and a leveling chin osteotomy for straightening.
With each treatment option the degree of jaw asymmetry improvement increases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a chin and jaw reduction ten days ago. It went well except that I have had worsening swelling each day after surgery. Today, when I woke up with even larger swelling on the left, I went to the ER to check it out and the ER doc after examining me was concerned I had a hematoma or an infection and ordered a CT scan with contrast. When the doc came back to my room he said the CT showed a large abscess on the left and a smaller one on the right and said I needed to get them drained. Then he consulted another plastic surgeon in the ER who looked at the CT and then called my plastic surgeon to consult him. After consulting each other it was determined these were pockets of liquid that can be a complication of surgery and would eventually be reabsorbed so no need for drainage. One determining factor was my WBC was normal however I just finished up my antibiotics yesterday. Also the ER doc sent me home on another week of antibiotics so I am wondering if he isn’t still somewhat concerned about possibility of an infection. So nothing is going to be done about the liquid pockets and the large one on the left is particularly bothersome and really has me concerned not only about the possiblity of infection as well as it is delaying my progress with recovery (worsened the swelling, discomfort, etc).
I know that you do a lot of jaw reduction surgery and would so appreciate to get your opinion re: these pockets. Should at least the large one be drained to reduce chance of infection and speed up my recovery?
A: Since you are within the first few weeks after surgery, these fluid pockets are either blood, serous fluid or a combination of blood. Bone when it is cut can ooze after surgery since it is hard tissue that does not have the capability of soft tissue contraction around the oozing exposed blood ‘channels’ and relies on compression of the overlying soft tissue on the bone (external wrap), an indwelling drain to pull off the fluid or just naturally stopping on its own. (which it may do if the bone removed is fairly superficial) Probably every facial bone reduction procedure gets a little bit of fluid which just naturally resorbs on its own within the first month after surgery.
Large (and it can be debated as to what constitutes large) pockets of fluid do have an increased risk of infection (good bacterial culture medium), can be uncomfortable when big enough and can prolong the recovery of one’s appearance and the final result because of increased resorption time. Draining them by needle aspiration or opening the incision and suctioning the fluid out can provide a prompt resolution to these concerns.
I can not tell you what you should do since you are not my patient for this surgery and that is between you and your surgeon.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about the possibilities regarding slimming down my face. It is just long and wide and does not look proportional to my body at all. What could be done to reduce the size of my face? I obviously see that there are limits of what can be done. Whereas I for instance could have jaw reduction and/or cheek cutting. But what sort of experience do you have here?
A: In facial reshaping surgery, slimming the face can be done by three different approaches depending on the dimensions involved. Normally the face could be vertically lengthened to make it look less wide. The face could also be made less wide (width reduction) without changing the vertical length. Lastly, a combination of vertical lengthening and width reduction can be done which often is the most effective.
Your facial dimensions and concerns (‘long and wide’) leave you with only facial width reduction options as you have noted. Cheekbone narrowing and jaw reduction would be the logical procedures of cboice. Whether this would include vertical chin reduction to help with the long face can be debated since vertical facial shortening works against facial width efforts.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I write to you in hopes that someone of your expertise can help as my case of jaw reduction is an uncommon one. I had a sagittal split osteotomy two years ago. I had excessively wide and disproportional jaws so I wished to have them reduced. An obvious solution would be to have both the osteotomy and masseter muscle resection as mine was quite prominent. My surgeon refused to do the muscle resection claiming that the muscle can grow back and undergo hypertrophy or something along those lines. Trusting his expertise, I agreed to undergo just the osteotomy and not any muscle resection. Due to this, I had him assure me he would shave off as much as he possibly and safely could, and he did so.
The results were mediocre as my hunch about most of the volume in my jaws were from my muscles was correct. But this is not the issue. About six months later, I woke up one morning and I felt a loss of sensation on my lower jaws, that made me think that it was swelling because it felt like my cheeks were drooping. It happened literally overnight. I saw my dentist and he couldn’t find any swelling or infection. I mentioned that there was a tingling sensation when he touched the affected area to which he advised that it was probably nerve damage. The affected area starts from the outer corners of my mouth going to the middle of my jawline. It feels like a loss of sensation which makes it feel like my lower cheeks are dropping and very intense tingling when touched. This makes activities such as talking more difficult due to the feeling of droopiness. I have attached an image to illustrate the affected area.
I have read that nerve damage heals by itself, but after over year and a half, there has been no signs of improvement. Some days are tolerable, but some days the feeling of droopiness is so severe that I can barely talk. I had a CT scan and the doctor advised me that my mandibles have been reduced significantly and possibly excessively.
Please advise me on your thoughts on my predicament, and possible steps I can take to deal with it. I honestly don’t know what to do, as all issues in regards to nerve damage are advised to wait it out.
A: Thank you for sharing your jaw reduction story and there are several aspects to it that defy a clear biologic explanation. The procedure you had done was most likely a lateral corticotomy where the outer layer of the bone over the jaw angles was removed. It is a form of a sagittal split osteotomy but not in the classic sense that the entire jaw was not moved. This is the most aggressive form of bony jaw angle reduction over shaving/burring and is aesthetically better than traditional jaw angle amputation. However it does run the risk of exposing and injuring the inferior alveolar nerve which runs in the medullary space of the mandibular ramus right below the outer cortex. Since you had the outer cortex removed this is the sensory nerve at risk for injury.
However, such nerve injury would have been apparent right after surgery and would not spontaneously appear nearly half a year later. In addition, your description and illustration of sensory nerve loss does not follow the well known anatomic distribution that this nerve covers. (lips and chin…not cheeks and side of the jawline) The only other nerve that could remotely explain your symptoms is that of the long buccal nerve which supplies sensation to the inside of the cheeks along the mucous lining. It is often inadvertently cut from any procedure of the mandibular ramus from the incision location but usually is of no consequence. But again, such a nerve injury would not just spontaneously appear many months later.
But any of these potential nerve issues are usually not repairable. In rare cases nerve decompression and/or nerve grafting are done. But these are only attempted when the location of the nerve injury is very clear.
I am afraid that I have neither an explanation or a solution to your postoperative concerns.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, I am ready to change the look of my face and am willing to spend whatever money it takes to do it. First I want to make my nose smaller as it is too big for my face I think. Second, I want to reduce my jaw size and I want to shift it little back and narrow it from the front view. If these are possible, please get back to me. I have attached some pictures of me for you to see my problems.
A: Based on your pictures, your nose is wide and broad from the front and has a low dorsal profile from the side. Your nose could be made to look smaller by a rhinoplasty which includes dorsal augmentation, nasal bone osteotomies, tip narrowing and nostril reduction. How much smaller it would appear would ultimately be controlled, particularly in the tip area, by the thickness of your nasal skin. From a jaw standpoint, I am a little perplexed that you want your jaw smaller when it already has a horizontal chin deficiency when view from the side. But in applying your request, it could be made slightly smaller by chin reduction by burring through a submental approach and jaw angle reduction by oblique osteotomies. I have attached some predictive imaging with those nose and jaw changes in mind.
Dr. Barry Eppley
Indianapolis, Indiana
