Your Questions

Q: Dr. Eppley,  I am 49 year old male and in good shape but yet I have a really bad sagging neck. Attached are photos of my neck from the front and both sides.  I’ve always had a sagging neck and had liposuction done 24 years ago so the fat under the neck is not great but the muscle and skin sag.  I’d like a sharper jaw line.  I consulted with a surgeon here who stated that to achieve a sharp jaw line, I’d need a full facelift and that a neck lift alone would only achieve a partial result.  This doctor stated that I should get a facelift and I don’t want a full facelift – I just want the neck tightened up.  Thanks for your time.

A:  Thank you for sending your pictures. The dilemma that you have is a common one for many men. They want to improve their neck and jawline but don’t want the facelift operation to do so. They believe that a ‘necklift’ will solve their concerns. What the plastic surgeon told you was correct…partially. You can only redrape the neck and jowl skin up over the existing jawline through a lower facelift procedure. The concept of a full necklift is really the same as a lower facelift….they are one and the same. There are other neck tightening procedures but they achieve their effects by making changes below the jawline.Thus they tighten but never really truly lift the neck…achieving only the partial result that your plastic surgeon correctly informed you of.

This dilemma leaves you with two options. First an isolated submentoplasty can be done from under the chin which will tighten up the neck angle but will have no effect on making the jawline sharper or more prominent.  (neck angle change) The other approach to augment the jawline with the submentoplasty. This would be particularly beneficial in your case as your jawline/chin is somewhat vertically deficienct. Improving the prominence of the lower jaw through a wraparound jawline implant with a submentoplasty will make the entire jawline stronger, will pick up loose skin in the neck and create a sharper neck angle.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin and maybe jawline implants. Do you favour the intra-oral or extra-oral approach for chin implants? Also, do you use silastic or porous implants? I have attached some pictures so you can see how short my chin is.

A: The first question to decide before one considers how to augment the jawline is exactly what type and degree of changes does one seek. As you can see in the attached imaging, you could just do chin augmentation only (side view prediction) vs. total jawline augmentation of chin back to the jaw angles. (oblique view prediction) Your chin is so short because your entire lower jaw is underdeveloped so your jaw angles are rotated up and backward (high) as well. There is also a debate to be had about your chin as to whether that should be done with an implant or a sliding genioplasty. Therefore, options include:

Chin implant only

Chin and jaw angle implants (performed)

Total jawline implant (custom)

Sliding genioplasty alone

sliding genioplasty combined with preformed jaw angle implants

But when it comes to using jawline implants of any configuration, silicone implants are far superior to Medpor and a submental approach (vs intraoral) is easier with a quicker recovery. The small skin scar is inconsequential.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of a jawline implant. I had a procedure to correct my jaw prognathism and teeth malocclusion. The surgery included sagittal split surgery of the mandible and LeFort osteotomy of the maxilla. While the LeFort osteotomy went well, unfortunately the sagittal split surgery which the surgeon had perform on my mandible were not very satisfactory. I’ve consulted with surgeon regarding the condition of my mandible and they all unanimously agree that my mandible were overly cut which resulted in an uneven contour of my lower jaw. The lining of my lower jaw project an unusual angle which stick out near the middle of my jaw. I had twice use fat graft to augment the area to recreate the mandible angle jaw line. While I am quite please with the result, unfortunately my body absorbs the fat rather quickly. I am looking into a more permanent solution, Such as silicone and synthetic bone. So here are my questions

1) Can silicone implant be used as an alternative to recreate my over dissected jaw line without adding width to my face?

2) I understand that synthetic bone can also be use to recreate my mandible jaw line. Assuming if silicone can also be used to recreate my mandible jaw line, which one would you suggest is a better option in term of result, Synthetic bone or silicone implant?

3) I am aware that both silicone implant and synthetic bone have its fair share of complication and risks.  I am aware that both synthetic bone and silicone could to some degree absorb one own bone resulting in asymmetry.  I am also aware that infection is also a likelihood. Beside the complication which I already mention, is there any other associated risk with either silicone implant or synthetic bone.

4) Unlike silicone, synthetic bone will create a permanent result. Assuming if I am unsatisfied with the result or infection occur, it there any alternative revision method?

5) What is the risk of nerve damages with this kind of procedure? 

6) And finally could you please provide a detail explanation of each method? For example how would you secure the silicone implant to the mandible? Where is the incision site? How long is the surgery? etc.

Thank you for your time and attention. I look forward to hearing from you very soon.

A: Thank you for telling your surgical history and describing your mandibular problem and need for a jawline implant. Your bony defect is really an absence of the jaw angle area. This is confirmed by the successful, albeit short-lived, fat injection augmentation results. In short, you appear to have an indentation probably at the location of the vertical bony cut of the sagittal split osteotomy. While there are multiple methods to treat this bony jawline/jaw angle defect, without question the best method is a synthetic implant. One can argue that it could be comprised of either silicone or Medpor material (I have used both very successfully) but the key is the implant design. Adding vertical length in an appropriate shape is far more important than the material used to create it. Either way the implant is placed from inside the mouth (like the sagittal split as done and secured to the bone by screw(s) Unlike your description, I have not seen the complications of implant migration, lack of permanency or a high rate of infections. There is no risk of nerve damage from this procedure. It is one I have done that is very similar to that of replacing cut off or amputated jaw angles. The key is designing the proper implant shape which can be made to add length but not width. Ideally, it should be made off of a 3D CT scan to exactly mimic that of a more normal shape. At the least it should be handmade off of a model made from a CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my left orbital and the left side of my jaw are fairly asymmetrical. I am interested in possible left cheek implant, andleft jaw/chin implant. I would actually also like to build out the left side of my nose and frontal bone if possible and fix my eyebrows as they are different heights. Also if you have suggestions I would like to hear them. I saw two plastic surgeons already, both said they could not help me . They did not actually look at me for more than a couple of seconds before they said that though.

A: Thank you for sending your pictures and indicating your objectives. To  summarize your facial asymmetry concerns, I list the following items:

1) Left jawline asymmetry (based on the arrow in the drawing this is located at the prejowl area which is the junction of the back end of the chin and the body of the mandible

2) Left cheek deficiency

3) Left brow bone-nasal deficiency

4) Left eyebrow excessive elevation

I don't know if any of these are from prior facial injuries or just your natural facial development. But either way, I can make the following comments/treatment recommendations:

1) It is not possible to improve your eyebrow asymmetry by lowering the higher left side. There is not a procedure that can accomplish that movement. Eyebrows can be lifted but they can not really be lowered. It is certainly possible to do an endoscopic periosteal release of the supraorbital tissues and see of that will accomplich some lowering (and there is little to lose by so doing) but I can't guarantee if that would really be effective.

2) The medial brow bone and upper nasal deficiency (which is bone based) can be built up by the onlay of a material through an upper eyelid (blepharoplasty) incision. While a wide variety of materials exist, I would opt for either an hydroxyapatite cement or a mersilene mesh onlay.

3) The cheek bone deficiency could be augmented by the use of a cheek implant placed through an intraoral incision.

4) The jawline deficiency (unless I am misinterpreting what your concerns are) appears to be a 'spot' area along the left jawline. I would build up that area with a mersilene mesh onlay to fill in the prejowl deficiency through an intraoral approach.

The three select facial skeletal deficiences (jawline, cheek and left brow-nasal) could be assessed in exact anatomic detail and custom implants made off of a 3-D skull model, but I don't think we have to go to that extent to get a good result. It may be ideal but I don't consider it absolutely necessary in your case.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am thinking about getting a custom jaw/chin implant. I think I have a small chin, vertically small jaw as well as narrow. Since I live in another city I can’t find any experienced surgeon. (or simply one I can’t trust) Would it be possible to get a CT scan done (of mandible and maxilla) and send it to you so you can build a wrap around jaw implant. How much would it cost excluding CT scan and the actual surgery? And then maybe I can find a surgeon in my city who can perform the actual surgery. I don’t want to get a genioplasty. Your help would be much appreciated.

A: Your assessment of your lower face is correct. Your entire jaw is vertically short from the chin back to the angles. Short of mandibular and/or chin osteotomies, a custom jawline implant that vertically extends the lower and chin is needed. That does require a 3-D CT scan which can be gotten in your city. It is then sent to a manufacturer to make a model of either just your lower jaw or your entire craniofacial skeleton. It is off of that model from which I can make a custom wraparound jawline implant. That design in your case is bigger in the chin area and tapers back because the length of your jaw angle is minimally deficient compared to your chin. I can certainly and the total cost to do it is $7500. (cost of model, fabrication and production and sterilization of implant) While you are certainly free to look around to find a surgeon who will place it, my guess is that won’t be easy because they have never seen an implant like that before and may be very uncomfortable (not to mention inexperienced) in its placement. It is not as simple as placing a standard chin implant.

Dr. Barry Eppley

Indianapolis, Indiana