Your Questions
Your Questions
Q: Dr. Eppley, I was wondering if you perform masseter muscle removal? And if it is a high risk surgery? Thank you!
A: The proper term for what you seek is…masseter muscle reduction. Complete removal of the masseter muscle is both impossible as well as would create severe masticatory and jaw movement dysfunction. Masseter muscle reduction can be done by either chemodenervation injections (Botox) or surgical electrocautery. Botox injections can be vert effective but usually have to be repeated for a sustained reductive effect. Electrocautery is a surgical procedure done from an incision inside the mouth. The muscle is raised up off the jawbone and the inner surface of the muscle is treated by electrocautery to create a muscle injury and subsequent atrophy for a more permanent effect. The use of electrocautery for masseter muscle reduction is relatively new but employs an old concept for tissue destruction by using electrical currents.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in masseter muscle reduction and am aware you offer electrocautery as a treatment. I have a few questions regarding this procedure :
1) Is it permanent? I understand Botox is used for this as well but it is temporary and radio frequency has also been used but lasts only for a couple years. I am looking for a permanent solution.
2) Are the effects significant? I have seen the effects of Botox for masseter reduction and I really liked it but as I previously mentioned the effects wear off. Will electrocautery provide the same effects or is it more subtle? If I find the result too subtle could I possibly come in for a second treatment?
3) Will there be any complications such as nerve damage, eating/movement limitations, premature sagging skin, or asymmetry?
4) Also, I have a dental Herbst appliance. Would that be an issue?
I look forward to your response. I apologize for the many questions.
A: Electrocautery is a form of surgical masseter muscle reduction. Somewhat similar to radiofrequency, it is a method of causing direct thermal injury to the muscle resulting in permanent loss of some muscle fibers. Unlike radiofrequency it it done through an open approach intraorally where the undersurface of the masseter muscle is treated. Through a combination of subperiosteal muscle release and direct electrocautery the size of the muscle mass is decreased as it heals. To answer your specific questions:
- Those muscle fibers that are directly thermally injured does result in their permanent loss. However, like liposuction which permanently removes some fat cells but weight gain can return by those fat cells that remain undergoing hypertrophy, the same can be said for muscle tissue. If the cause of the masseter muscle hypertrophy persists the remaining muscle fibers can become hypertrophic and muscle volume returns.
- Generally the effect masseter muscle reduction by electrocautery are similar to the effects of Botox injections. Further reductive treatments can be done.
- Other than some temporary muscle stiffness (trismus) there are no other adverse effects. It is just an aesthetic question of what degree does the overall muscle mass shrink.
- An indwelling oral appliance is not a preventative factor for having the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am at a stage where I am set on receiving a frontal jaw width reduction procedure, but the question really comes down to which procedure. I thought jaw reduction surgery will be the answer to my problems, but I know that I also have quite large masseter muscles. Will jaw reduction surgery alone slim down my jawline? I know that Botox is an option, but I am looking for a more permanent solution. I have heard of masseter muscle excision. What do you think about this procedure?
A: In looking at your pictures, I can see that your very wide jaw angles are most likely a result of a combination of bony angle protrusion and masseter muscle thickness. How much the bony angle contributes to your jaw width can really only be determined by an x-ray (frontal cephalometric x-ray or 3D CT scan). This would be of particular relevance if an angle thinning procedure is to be done as opposed to an angle amputation procedure. Particularly with an angle thinning procedure, the masseter muscle must be managed (reduced) in some fashion of a real posterior jaw width reduction is to be achieved. Subtotal excision of the masseter muscle is never a good idea and that is prone to intraoeperative bleeding and postoperative facial irregularities. This is why most masseter muscle reductions are done by Botox injection since it is far safer…albeit temporary in many cases. I have evolved to a different approach to master muscle reduction with bony angle reductions and that is electrocautery. By cauterizing the inside of the muscle where the bony is lifted off of the bone, this causes a natural shrinking of the muscle due to fiber injury. This takes months to see the final outcome as the muscle shrinks down as it heals. But it can produce up to 25% to 33% reduction of the muscle width.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was inquiring to see if masseter muscle reduction surgery is something you can do? So rather than a jaw reduction of the bone, just reduce the muscle in the jaw. I’d be coming in from Arizona for surgery so approximately how much would something like that cost me? And what would the recovery time be? Thank you.
A: Masseter reduction surgery can be done but it does slightly different than one would think. You do not go in and cut a portion of the muscle out as that would be very bloody and would likely leave the outer facial contour irregular when it heals. Rather the muscle is lift off the bone from the inside of the mouth and its inner surface treated by electrocautery. This will cause some muscle fibers to die and a portion of the muscle to atrophy obver time. Also Botox is injected into the muscle at the same time to help the atrophy process. I assume you are aware that you can treat masseter muscle hypertrophy with repeated Botox injections to help it shrink without surgery.
Other than some swelling there really is not much recovery or limitations after surgery. The jaw will feel stiff for a few weeks from the muscle treatment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an unfortunate fat graft and if englarged my masseter muscle (among other things). I am looking to reduce the masseter area surgically. I do not think that botox will help as some of the bulk is fat. I was told that it was placed UNDER the masseter. Do you know or can you suggest any local maxillofacial drs that could help me with this? I am worried about nerve damage. I also had too much fat along the lower jaw and it looks like jowling. What are your thoughts on smart lipo type procedures? I had regular liposuction to try to fix this with no positive improvment at all. Thank you for your informative website and any advice you can give me.
A: Given that you had liposuction of the masseter/jowls with no improvement, this would indicate that the fat is not in the subcutaneous space (of which you have already mentioned) and therefore no form of liposuction will work. This means then that the fat is either under the masseter muscle, in the masseter muscle or a combination of both. I would think it would be very difficult to get all the fat under the masseter muscle and some of it is likely in the muscle as well. Thus removal would require an intraoral submasseteric approach to get access to the fat. There is no risk of nerve injury in doing so so that should not be a concern. The only issue, in my mind, is how much fat could be removed from this approach and whether any masseter can or should be taken if there is not much fat visible in subperiosteal/subfascial plane. One way to really know where the fat is is to get a high resolution MRI of the masseter area. That would give a good idea beforehand of the success of such a procedure. The jowling fullness is another issue and, if not improved by liposuction, may have to consider some form of a jowl lift for improvement.
I can not give you any recommendations for any local doctors that may perform such procedures as I would think it would be very uncommon and may even make most uncomfortable.
Dr. Barry Eppley
Indianapolis, Indiana
