Your Questions

Q: Dr. Eppley,  I am interested in orthognathic surgery even though my bite (Class 1) normal. Thus any orthognactic surgery would be cosmetic and not functionally beneficial. It just appears to me that my face and the bones in it did not grow in an optimal aesthetic direction. It seems that my face is too long and has dropped to a gaunt look with a flat midface. Could this be due to a downwards grown maxilla or other bones? Can it be fixed with a maxillary impaction?

A: Your malocclusion is modest and within the confines of a general Class I occlusion. The point being is that it is not the source of your aesthetic facial concerns. The difference between your child face and your adult one is the relatively standard change between the 2/3s dominance of the upper face in childhood to the completion of facial growth in early adulthood with a reversal in that proportionate relationship. Whether your face is too long is a personal assessment and not a function of actual facial structure disproportions.

Changing your facial proportions is done by decreasing the vertical length and improving the midface projection width. This is usually best done by a vertical wedge reduction genioplasty (chin) and malar-submalar implant augmentation. Doing a maxillary impaction would bury your upper teeth under your upper lip and would also require a concurrent mandibular osteotomy to keep your bite relationship from changing unfavorably.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Wondering if you do maxillomandibular advancements surgery for sleep apnea or know of any other plastic surgeons that are also dentists/oral surgeons that might do this procedure. Would prefer to have a oral surgeon that is also skilled as a plastic surgeon in hopes of having not only a successful surgery, but also a better cosmetic outcome. Thank you.

A: I do perform bimaxillary (maxillomandibular) advancements for obstructive sleep apnea. You are correct in that there can be a delicate balance between how much to move the face below the eyes forward and not so much that it creates facial disharmony. (resultant infraorbital-malar hypoplasia) As a general rule it is recommended to move the maxilla and mandible as far forward as possible. (usually about 10mms) But in some patients that may well create a ‘protruding lower face’ that is disproportionate to the natural facial appearance above it. This requires insightful planning beforehand based on the patient’s facial shape. Using computer imaging and VSP (virtual surgery planning) for the facial bones from the patient’s 3D CT scan, more thoughtful surgical planning can be done that takes into account both the functional and aesthetic needs of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,   I was just curious if you personally perform orthognathic surgery on a routine basis (I know your website primarily focuses on plastic surgery procedures rather than maxillofacial ones) and if so, whether you ever perform it in an outpatient setting?  I know that I have a long road with dental work and orthodontics before I could even consider it, unfortunately, but I think the only way I could realistically afford to have jaw surgery is in an outpatient setting as I have heard how outrageously expensive it is in the hospital setting (and I do not expect insurance coverage in my situation).  My understanding is that some surgeons do in fact perform it in outpatient facilities (which is a more recent development due to the high cost) and I was wondering if that is something you have personally done or are familiar with.  

A: Various forms of orthognathic surgery have been performed in surgery center locations for decades. While it is true that increasingly limited insurance coverage has made the concept of out of pocket orthognathic surgery more common, it is not new to perform it outside of a hospital setting. The key concept is that some orthognathic procedures can be performed this way but not all. Isolated maxillary (leFort 1), mandibular (sagittal split) and chin (sliding genioplasty) procedures can be safely done as an outpatient. It is when these procedures are combined, which often may be needed, that a hospital setting is not only preferred but should not be done outside of it due to aiway and recovery concerns.

Dr. Barry Eppley

Indianapolis, Indiana

Rich Text Area Toolbar Bold (Ctrl + B) Italic (Ctrl + I) Strikethrough (Alt + Shift + D) Unordered list (Alt + Shift + U) Ordered list (Alt + Shift + O) Blockquote (Alt + Shift + Q) Align Left (Alt + Shift + L) Align Center (Alt + Shift + C) Align Right (Alt + Shift + R) Insert/edit link (Alt + Shift + A) Unlink (Alt + Shift + S) Insert More Tag (Alt + Shift + T) Toggle spellchecker (Alt + Shift + N) ▼ Toggle fullscreen mode (Alt + Shift + G) Show/Hide Kitchen Sink (Alt + Shift + Z) Format – Paragraph Paragraph ▼ Underline Align Full (Alt + Shift + J) Select text color ▼ Paste as Plain Text Paste from Word Remove formatting Insert custom character Outdent Indent Undo (Ctrl + Z) Redo (Ctrl + Y) Help (Alt + Shift + H) Q: Dr. Eppley,   I was just curious if you personally perform orthognathic surgery on a routine basis (I know your website primarily focuses on plastic surgery procedures rather than maxillofacial ones) and if so, whether you ever perform it in an outpatient setting?  I know that I have a long road with dental work and orthodontics before I could even consider it, unfortunately, but I think the only way I could realistically afford to have jaw surgery is in an outpatient setting as I have heard how outrageously expensive it is in the hospital setting (and I do not expect insurance coverage in my situation).  My understanding is that some surgeons do in fact perform it in outpatient facilities (which is a more recent development due to the high cost) and I was wondering if that is something you have personally done or are familiar with.   A: Various forms of orthognathic surgery have been performed in surgery center locations for decades. While it is true that increasingly limited insurance coverage has made the concept of out of pocket orthognathic surgery more common, it is not new to perform it outside of a hospital setting. The key concept is that some orthognathic procedures can be performed this way but not all. Isolated maxillary (leFort 1), mandibular (sagittal split) and chin ( sliding genioplasty) procedures can be safely done as an outpatient. It is when these procedures are combined, which often may be needed, that a hospital setting is not only preferred but should not be done outside of it due to aiway and recovery concerns. Dr. Barry Eppley Indianapolis, Indiana Path : p  » span

Q: Dr. Eppley, I have had two double-jaw orthognathic surgeries that didn't cause any lasting problems to the sensation in my nose or upper lip, but this last surgery did. Ever since the last surgery, the area just inside and under my nose is constantly aching and my upper front teeth and gums are still numb. Could the hardware that that I've circled in the panorex x=ray be causing these problems for me? Do you think that removing this hardware could resolve it? I'm asking because even if I don't have more jaw surgery, I don't think that I can stand this aching/burning/numb feeling inside my nose and upper teeth much longer. I was on Tramadol for several months and then switched to Lyrica – but nothing really helps.

A: While titanium plates and screws are non-ferromagnetic and do not corrode, the location of the metal hardware could certainly be a contributing cause as it is positioned around the pyriform aperture directly above the tooth roots and at the base of the nose. While most LeFort osteotomy patients do have hardware in similar areas, the right-sided location of the hardware does cross over the premaxilla more than is customarily seen. While no one can say for sure if this hardware is the cause of your dysesthesia, there is one way to answer that question definitely…remove it. I would remove both medial or paranasal maxillary plates and screws to be sure all devices are gone from the paranasal areas.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was looking into orthognathic surgery as I have a receding chin and asymmetrical jaw. I was wondering if this procedure helps shorten the length of the face? Also does it have any type of effect on the cheekbones? I have flat cheekbones and was wondering if this surgery would have any type of affect on them.

A: Depending upon the type of orthognathic surgery done and the bony movements, it may well improve jaw asymmetry and a shorter chin, although often a separate chin osteotomy needs to be combined with it. But it would be uncommon that orthognathic surgery will shorten the vertical length of the face. It may make no significant vertical change or may even lengthen it but vertical shortening will only occur if the maxilla is being impacted as part of the treatment plan. What is for absolute certainty is that the cheek bones will not be affected in any way, positive or negatively, with orthognathic surgery. The horizontal bony cut at the LeFort 1 level goes below the cheek bones just above the roots of the upper teeth. Cheek augmentation can be achieved at the time of orthognathic surgery, however, by the simultaneous placement of cheek implants above the level of the osteotomy cut on the flatter cheek prominence.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I read about you on Real Self and would like to have surgery under you. I have an short face (abnormally short lower third of face) but, oddly, also mandibular prognathism. Could you push my jaw back and at the same time lengthen my face?  I have attached my original front and side photos, and also some virtual post-surgery photos to aid in your diagnosis. The lower third of my face is already equal to 1/3 of the length of the midface. After bimaxillary orthognathic surgery (see the post surgery photos), notice how my lower third becomes extremely short. Although the post surgery side profile is good, the post surgery front profile is horrendous! I am also concerned about the unaesthethic effects on the nose of lefort 1 as well as the risk of bimaxillary protrusion. I was wondering whether you could beautify my side profile without making the lower third shorter, perhaps with orthognathic surgery alone, vertical distraction + orthognathic surgery or lefort 2 alone. Please let me know of any other options. Thanks!

A: The virtual after surgery photos that you have shown are not realistic nor would they look that way. You undoubtably need a LeFort 1 advancement osteotomy but whether you need or can have any change to your lower jaw is unknown based on the information you have presented. What will happen or be needed to the lower jaw completely depends on your occlusion (bite) and how it fits when the maxilla comes forward. You can not just move your lower jaw any way you want, it does not work that way in orthognathic surgery. You may need the lower jaw set back somewhat with the maxilla coming forward but that will not change the vertical height of the lower 1/3 of your face in any significant way. You do not need anything more complex than a Lefort 1 advancement with or without a mandibular setback.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had orthognathic surgery three years ago when my upper jaw was moved forward. While the surgery was successful and my underbite was fixed, I have a persistent problem with my lower lip. My lower lip hangs down and I have too much tooth show. I notice now that when I pull my lower jaw back, the lower lip comes up and corrects the problem. I am now thinking that instead of having my upper jaw brought forward, I should have had my lower jaw moved back. What do you think?

A:  It is hard for me to pass any comment on your previous orthognathic surgery, not having seen any preoperative x-rays or work-up. It can be difficult to determine in a Class III malocclusion (cross-bite) whether the upper jaw should come forward or the lower jaw to go back. Either manuever will correct the malocclusion but they can have different aesthetic outcomes, even if that can be somewhat subtle.

Everyone when they move their jaw backward creates more lower lip and allows it to move upward on the front teeth. So I don’t necessarily think that you doing so proves that a sagittal split setback of the mandible was a better procedure than the LeFort advancement.  

At this point, this discussion is somewhat irrelevant. You can’t undo your jaw relationship without repeating your orthodontics and undergoing further orthognathic surgery…a process that would take years and likely result in some permanent loss of sensation of the lower lip from the mandibular setback.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, My upper jaw (maxilla) seems to be slightly recessed and the natural outward projection of maxilla is not present creating an unusually flatter profile in mid-face. My chin is also recessed but interestingly don’t have any bite problem. After extraction orthodontics(to treat crowding) the problem seems to have aggravated and now the upper teeth show way behind the upper lip and now the dental arch provides minimal support to the lip. This makes the upper lip to hang without proper base support resulting in speech problems. (lisp) I also had an unsuccessful chin surgery (implant removed 1 yr back) creating awkward tensions in chin fold area and trickier lower lip movement. Combined with above, my face is in pretty bad shape and preventing me to achieve a good speech. Kindly suggest what are the options.

A: By your description, it sounds like the fundamental problem is that of maxillary horizontal retrusion. That has been magnified by the teeth extractions for orthodontics which have pulled the anterior maxillary teeth (and the lip support) further back. It would be important to have a full facial skeletal workup on you (photographs, x-rays and dental models) to determine the viability of orthognathic surgery. (maxillary and mandibular advancement combined) That would treat the fundamental underlying problem of a deficient skeletal base. Onlay implant facial augmentation is another option (midface and chin implants) but should only be considered if the orthognathic surgical approach was either not possible to do or was too extreme an approach to go through.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can a lower jaw setback be combined with a lower gfacelift during the same procedure? Have you yourself done this before?

A:  The technical capability of performing a combined orthognathic procedure, like a mandibular setback, with a facelift is certainly possible. The need for it is so rare, however, that it would be hard to a surgeon that had ever done it together. There are several reasons for its rarity. By definition, a facelift would be done in an older patient while orthognathic surgery is usually done in a younger patient. Thus, the mainstream population of each procedure are at diametric ages. There is also the consideration that the  type of surgeon that performs these procedures are quite different. Most maxillofacial surgeons have little or no training for facelift surgery and most plastic surgeons have little or no training in orthognathic surgery. While plastic and maxillofacial surgeons certainly can work together and coordinate these surgeries, most plastic surgeons would probably prefer to defer the facelift to a later date due to swelling considerations.

With all of that being said, a mandibular setback and a facelift can be done together. The question is not whether they can be done together but whether they should. While each operation poses a ‘surgical opportunity’ to do additional procedures, you want to make sure that the patient can still get a result that would be comparable if either procedure was done alone. Surgical opportunity should not be more important than an outcome. In that regard, I would have to know more about how much mandibular setback is needed and the proposed technique (sagittal split ramus osteotomy vs vertical oblique osteotomies) and the degree of neck and jowl sagging that exists. Then I could answer the question better about whether such a combination is a good idea.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in learning about the cosmetic effectiveness of doing both zygomatic osteotomies with orthognathic surgery. I have seen some plastic and oral surgeons and I am told I have what they call a class 2 malocclusion with a restrusive mandible and maxilla, low sunken zygomas and mid-face with the outer edges of my eyes drooping. I am going to have orthognathic surgery in near future for functional reasons, sleep apnea, tmj problems, snoring, and to improve breathing while I am awake by enlarging the air ways. But cosmetically my cheeks and drooping eyes I would also like to improve. There are multiple modified LeFort osteotomies that help with filling in the face, but I am looking for something that will address the drooping outer edges of the eyes. What are the risks involved for a zygomatic osteotomy? (like double vision) How do you feel about the procedure being performed with orthognathic surgery? How cosmeticly effective is it when both done together? (other opinions suggesting best done separately) Can you achieve symmetric cosmetic pleasing effect? Not too interested in implants due to risks of dislodging and erosion, very active lifestyle, feel it would get in the way.

A: Let me give you some general thoughts about your questions with the caveat that I have never seen your photographs or x-rays and am only working off of your description of your face.

Your orbitozygomatic facial skeletal arrangement is such that the cheek bones are flat and recessed and the lateral orbits may have a little downslanting orientation. (tilted horizontal orbital axis) That problem alone, which occurs commonly in more severe deformities such as Treacher-Collins, requires a combination of  a C-shaped orbitozygomatic osteotomy with bone grafts to improve the total three-dimensional bone problem. Yours may not be as severe but the 3-D problem is likely the same. Beyond the fact that this requires a coronal (scalp) incision to do the bone cuts properly, it would be very difficult to do this simultaneously with any form of a LeFort I osteotomy. Between the scalp scar and the type of osteotonies needed, this treatment is likely too severe for correcting a more mild orbitozygomatic bone problem.

While there are some high modifications of a LeFort I osteotomy, they are restricted in how the zygoma moves and will only bring it forward but not out. (no width improvement) These are interesting operations on paper and in surgical diagrams but have never proven very practical or effective. That is why they simply are not done or rarely attempted.

The conclusion is that any form of an orbitozygomatic osteotomy is too big of an operation, will leaves palpable (able to be felt) bone edges, and also requires bone grafts. This is why the best approach, even if you don’t desire it, is to do some form of a cheek implant with lateral canthal repositioning of the eye. These are far simpler, much more cosmetic effective, have less complications (both short and long term) and can be combined with orthognathic surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q : My jaw is asymmetrical. It is tilted and is also bigger on one side. I have read some of the articles you have written on facial asymmetry and wanted to ask you about how best to correct my problem?

A: Jaw or mandibular asymmetry is often a major cause of facial asymmetry. Often the entire side of one’s face is different if one looks for it carefully. Sometimes it is the lower face (jaw) that is the most significant part, other times the cheek, orbital, and forehead bones are equally involved and part of the problem. It is critically important to assess both sides of the face from top to bottom with photographs and measurements from different angles to get an accurate assessment.

In most cases of minor to moderate facial asymmetry, camouflage techniques are used. This means the use of facial implants to lengthen and broaden the smaller and flatter facial prominences. These are good options for jaw angles and cheeks. Chin asymmetry is often better done with osteotomies where the bone can be differentially lengthened between the vertically shorter and normal sides. Soft tissue deficiencies can be simultaneously improved by fat injections.

If significant facial asymmetry exists and one’s occlusion (bite) is very tilted, another consideration is orthognathic surgery. In younger patients this may be a better option if one is prepared to go through several years of preparatory orthodontics and then jaw surgery to directly treat the primary bone, differential bone growth.  

Dr. Barry Eppley