What Is Your Technique For Masseteric Muscle Disinsertion After Jaw Angle Implant Surgery?
Q: Dr. Eppley, I recently read about masseter muscle reattachment after mandibular angle surgery as one of my own patients has presented with masseter muscle disinsertion on the right side after revision of his mandibular angle implants performed in January of this year.
Recognizing your expertise in jaw implant surgery, I am hoping that you can help me by commenting on whether you are using a similar operative repair technique as what I read in the article and/or or whether you have any additional pearls of wisdom for successfully performing this reconstructive surgery.
In your experience, how often does masseter muscle retraction occur following mandibular angle implant placement and how can I prevent this from occurring in the future?
Have you generally found it necessary to remove the existing implant at the time of masseter muscle reattachment?
How many (and what type of) sutures do you generally place in order to resecure the masseter muscle to the mandibular bone?
Do you augment the repair with Alloderm or temporalis fascia?
Is botox treatment of the retracted masseter muscle a possible alternative to surgery?
A: In answer to your questions:
1) I have not found the masseter muscle reattachment procedure particularly effective. When combined with having to place a neck scar to do so, I rarely ever perform it anymore.
2) I treat the soft tissue jaw angle defect today with either the subcutaneous placement of thick Alloderm, perforated ePTFE sheeting or custom made ultrasoft silicone jaw angle implants. This camouflage approach has proven to be far more effective in my hands. This can be done through a less than 1 cm skin incision right over the angle edge.
3) Some patients may merit treatment of the retracted bulge of the muscle with Botox.
4) In terms of prevention, very careful subperiosteal elevation along the inferior border beginning anteriorly at the body of the mandible back around the angle is needed. This technique is far more gentler than the standard stripping done for a sagittal split osteotomy. This will prevent most masseter muscle detachment issues.
Dr. Barry Eppley
A detailed description and pictures of your concerns allows for the most informed response.