A custom wrap around jawline implant offers an unparalled approach to jawline augmentation. Made from a 3D CT scan it is designed to provide varying amounts of chin and jaw angle dimensional changes that are connected as a single piece implant. Because it is one larger implant it usually has to be placed through a three-incisional technique, one around the chin and the other two intraorally back by the jaw angles.
Because each incision is much smaller than the length of the implant, the sides of the implant must be initially introduced through the chin incision. The sides of the implant are then fed through the side tunnels back into the jaw angle area. The flexibility of the implant permits such a placement technique through the comparatively small incisions.
The ability to thread a custom wrap around jawline implant from front to back depends the size of the jaw angle portions. If the back portion of the implant is fairly big, trying to pass it through a subperiosteal tunnel below the mental nerve risks a stretch or tear injury to it. In these implant sizes it is better to split it in the middle and thread it from back to front. The smaller chin portion is safer to pass under the mental nerves.
Reuniting the split custom wrap around jawline implant in the midline once positioned can be done with sutures or screws. Getting two vertically split midline implant sections perfectly together can be challenging. An alternative strategy is to create an interlocking connection down the midline when the implant is sectioned.
When reuniting these interlocking midline segments, like lenticular puzzle pieces, the precision of the implant design is re-established over the chin.
The aesthetic correction of a retroclined or sloped forehead can be done by a variety of surgical techniques. Fat has become popular as an ‘easy’ injectable method of augmentation but it is important to remember that it is best used for soft tissue augmentation. In most cases forehead augmentation is a bony deficiency not a soft tissue one. Fat injections into the forehead can be unpredictable in terms of volume retention and smoothness so it is not a primary forehead augmentation procedure.
A variety of implant materials can be used in the forehead. Bone cements have a long history as a skull augmentation material including in the forehead. While effective their use requires a near coronal scalp incision for placement and is prone to irregularities and edge deformities. Their shape also depends on the surgeon’s artistic skills and being able to translate the patient’s aesthetic desires into a moldable shape.
All of the potential negative aspects of bone cements for forehead augmentation are eliminated by the use of a 3D custom forehead implant. The exact shape and edging of the implant are determined and made before surgery. The insertion of the implant is done through a much smaller scalp incision due to its flexible nature. Tissue ingrowth into the implant is fostered by the placement of numerous perfusion holes. The outer smoothness of the augmented shape is assured by its preoperative design.
A custom forehead implant offers a superior method of aesthetic forehead contouring in my experience. While it still requires accurate placement of its predetermined design, the number of variables that can lead to undesired effects is reduced by its basic concept.
When most people (and many surgeons) think of midface augmentation, the use of cheek implants comes to mind. While cheek implants certainly do augment one area of the midface, they only cover one specific of the midface…the upper and outer corner of it.
Most of the midface lies between the cheeks and consists of the maxilla (upper jaw) and nasal base bones. From a bone standpoint midface augmentation is usually perceived as either a Lefort I or maxillary advancement (low midface) or a LeFort III osteotomy for a total midface advancement.
But the midface can be augmented with implants just as effectively, or even more effectively, as moving the bone and way beyond what simple cheek implants can do. The use of a custom midface implant from a 3D CT scan can cover the entire midface from the pyriform aperture up to the cheeks. Such an implant can be inserted completely through an intraoral approach.
A custom midface implant is designed to increase central facial projection. It is an effective approach for patients with flat or concave facial profiles or for patients with negative orbital vectors. The point of maximum projection can be altered to either a low maxillary-anterior nasal spine point or higher up along the cheeks and infraorbital rims.
The typical ranges of increased midface projection for these custom implants is between 3mm to 7mms in most cases. Because it covers a broad surface area (the entire midface), its effect is greater than one would initially think.
Background: Augmentation of the jawline by today’s standards usually means chin and jaw angle increases. This three-point approach typically uses performed chin and jaw angle implants. With the many different types of facial implants available today, most male and female demands for jaw augmentation can be met.
When using the three implant technique for jaw augmentation, there is a need for accurate placement of each implant. Implant malposition is the number one complication of facial implant surgery. Bilateral facial augmentations, such as the cheek and jaw angles for example, are prone to a unique risk of implant malposition…asymmetry. Even very slight differences in jaw angle implant positions can create visible external asymmetries that can be bothersome to the patient.
If you add up the general risks of implant malposition and size concerns with a single facial implant (around 10%), it is easy to see what the revisional surgery risks are in a three piece jaw augmentation procedure. Since surgical risks are additive for each implant, a total jawline augmentation with standard implants has risks of 30% or greater for issues that may merit revisional surgery. While it is true that some patients are more particular than others about ‘perfection’ or a result that meets their ideal aesthetic goals, my experience has been that most patients seek a result that is more than just close.
Case Study: This 21 year-old female previously had chin and jaw angle implants palced for a complete jaw augmentation effect. While she liked the over all augmentation effect, she as bothered by the jaw angle asymmetry and the lack of a smooth jawline from front to back. A 3D CT scan showed a good chin implant position but obvious jaw angle implant asymmetry with standard widening angle implants. (She also had cheek implants which were asymmetric but that is not relevant to this case study)
A custom jawline implant was created using the dimensions from her prior implants with some small changes. (9.5mm horizontal chin augmentation, 12mm wide jaw angle) Equally importantly the chin and jaw angles were connected by a smooth implant bar on each side.
This is a great example of how the custom jawline implant may keep many of the sizes of the standard implants but makes the entire jawline augmentation smooth and connected…like one’s natural jawline. This can be appreciated in the overlay of the existing implants (in green) with the new implant design (in light blue) on the implant planning pictures.
Under general anesthesia her existing submental and intraoral incisions were used to remove her indwelling implants and replace them with the one piece jawline implant.
A three-piece jawline implant augmentation can be prone to less than ideal implant positions and external aesthetic effects. A custom jawline implant can be used for a replacement. The existing implants serve as an invaluable guide in how to design the new one-piece implant.
1) A three-piece jaw augmentation approach using standard implants is prone to implant malpositions.
2) A custom jawline implant can replicate what standard jaw implants can do but in a single implant that is less prone to jaw angle malpositions.
3) A one-piece jaw implant permits a smooth linear connection between the chin and the jaw angles.
The use of a custom jawline implant is the most effective technique to reshaping the lower face. Its one-piece design allows the changes in the front of the jaw (chin) and the back of the jaw (jaw angles) to be connected in a smooth linear fashion.
While the one-piece design of the implant has numerous aesthetic advantages, it does pose a unique intraoperative challenge. How does such a jawline implant get inserted? The sheer size of the implant is completely different than much smaller chin and jaw angle implants which are placed through single incisions.
The custom jawline implant is usually placed through a three incisional approach. There is the two intraoral posterior vestibular incisions and the anterior chin incision. The chin incision can be done either through the skin under the chin or from inside the mouth. Through these three incisions a subperiosteal tunnel is made that connects them going under the exit of the mental nerve from the bone. The custom jawline implant is positioned into place by passing the back parts of the implant through the chin incision
The size of the jaw angle part of the implant determines how easy or hard the custom jawline implant placement technique is. If the jaw angle implant part is very large it may be impossible to pass it under the tunnel that connects the chin and the jaw angle without significant risk of injuring or even tearing the mental nerve.
In these cases the custom jawline implant is split in the middle and each half passed from back to front. Since the chin segment is smaller it passes easier through the subcutaneous tunnel and poses less risk of injury to the mental nerve. The implant halves are then reunited in the midline using either sutures or screws.
Background: Facial reshaping surgery is a broad collection of bone augmentation and reduction procedures. Almost all of the facial bone augmentation procedures are done by some form of onlay augmentation, most commonly preformed by preformed implant styles. Of all available facial implants the four most common areas augmented are the chin, nose, cheek and jaw angles. All of these represent facial projection points where augmentation can make a big difference on the perception of the face.
Of all available facial implants the hardest ones to choose a proper style and then surgical place are the cheeks and jaw angle locations. Cheek implants are technically easier to place but getting the right style of implant can be difficult as they are major gender aesthetic differences in this part of the midface. Jaw angle implants have less style choices but is very hard to place and position on the bone properly and are highly prone to malposition.
The success of facial implants is most fundamentally controlled by the style and size of the implant chosen. A perfectly performed facial implant placement that heals without complications may be viewed as a surgical success. But if it fails to meet the patient’s facial change goals it is still an aesthetic failure. Case Study: This 36 year-old male had a prior history of standard cheek and jaw angle implants placed one year previously. The implant creased undesired facial shape changes. The submalar cheek implants created a more feminine ‘apple cheek’ look rather than the high cheekbone look he desired. He had high jaw angles but widening jaw angle implants were used. This made his face look look wide and fat. A 3D CT scan showed that the implants were well placed but they simply were the wrong style and size. New custom cheek and jaw angle implants were made that were designed to create a high cheekbone look and vertical lengthening of the jaw angles. The differences between the old and the new custom implants can be seen in the 3D overlay. Under general anesthesia a complete intraoral approach was used to remove the old implants, perform capsulectomies, extend the pockets and place the new implants. The horizontal portion of the chin part of the jawline was removed as that the chin ended up more square but did not additional horizontal projection.
How to choose proper facial implant style and size is not only not an exact science, it is really not something that any plastic surgeon learns to do in their training. It is still a judgment by the surgeon who tries to understand the patient’s facial goals and then makes an aesthetic judgment about implant selection. Highlights:
1) Facial reshaping surgery often includes cheek and jaw implants.
2) Incorrect styles of cheek and jaw angle implants can lead to undesired facial shape changes.
3) Certain types of facial reshaping changes requires custom cheek and jaw implants to achieve the patient’s desired aesthetic result.
Dr. Barry Eppley
Background: Contour deformities in the temporal region can be caused by either bone or muscle deficiencies. They often develop from prior surgeries such as craniotomies for tumors and infantile cranial vault surgeries for craniosynostoses. Elevating the temporalis muscle at any age often results in muscle retraction and/or muscle atrophy. Even though the surgeon may resuspend the temporalis muscle at the end of the operation some degree of temporal contour deformity often still occurs.
Recontouring of many temporal deficiencies can be done by either fat injections or implants. Fat injections have their merit but they can be unpredictable in terms of both survival and contour shape. Implants of various materials have been used for decades for many forms of skull contouring. While many cranioplasty materials have been used in the temporal region, they have less than ideal properties because they are intended for bone contouring not that of muscle augmentation.
The temporal region is comprised of a thick layer of muscle in its anterior region beside the eye. When the muscle retracts or atrophies a pronounced indentation will occur. Filling in the indentation with a satisfactory aesthetic result can be difficult as this is a soft skull area and not a hard one.
Case Study: This 36 year-old male wanted to improve the appearance and feel of his tenporal regions. He had a history of a congenital skull deformity which underwent early surgery as an infant. As an adult the resultant temporal hollowing was treated by unknown temporal implants which he did not like because they were very hard and had visible irregularities and edges. A 3D CT scan showed multiple regular circular indentations in the upper temporal region which was consistent with Medpor style temporal implants.
New custom temporal implants were designed from the 3D CT scan by initially adding on the missing bone since the the scan cut off the upper temporal bone.
Under general anesthesia the temporal region was approached using his existing incisions from prior surgeries. The existing Medpor implants were removed in their entirety. Their underside revealed the multiple pegs of material for which they are recognized. The new custom temporal implants were put in as replacements with some trimming of its bottom thicker edge. Multiple 3mm perfusion holes were placed through the implants prior to their placement.
The best way to change the shape of the jawline for many men is a custom jawline implant. Custom designed from the patient’s 3D CT scan, the implant is usually a wrap around style that augments the entire jawline. Changing the shape of the jaw angles and jawline in a continuous fashion around the arc of the jaw can create a dramatic change if the patient so desires.
While such a jawline implant is custom designed, how to create the exact look that the patient wants from such a designing process remains more of an art form rather than an exact science. Besides the implant design the exterior facial change that is achieved is affected by the overlying soft tissues as well.
Having designed and implanted many a custom jawline implant I am still always amazed when seeing the actual implant at the time of surgery. When designing such implants I may think they are big or small but seeing them in person is almost always a revelation. The size of all custom jawline implants fits into my relatively small hand.
Inserting such a facial implant always seems daunting given its size and how it compares to much smaller standard cheek and chin implants. But a three-incisional insertion technique allows a safe and effective placement method.
Background: The lower third of the face is a very important component of the male face. Whether one choices to call it more attractive or masculine, a well defined jawline creates an essential aesthetic feature of the lower face in a man. While fashion and beauty ideals change across various cultures and periods of time, there has never been a time in history where a weak or short jawline in a man was viewed as desirous.
There are numerous methods of jawline augmentation, all of which have a role to play in male facial enhancement. Provided one has a stable and well interdigitated bite (occlusion), most augmentation methods involve some form of implant placement. There is a role for a sliding genioplasty in more severe underdevelopment of the jaw but it is far less frequently done than that of implants.
Jaw implant augmentation consists of either using standard implant shapes and sizes or having a custom jaw implant made. The decision between these two choices comes down to which approach can best create the desired aesthetic result. Or to put it another way…can standard chin and jaw angle implants suffice? Does one have to go as far as having a custom jaw implant made? That answer depends on two dimensional issues; 1) Do the desired chin and jaw angle changes fall within what standard implant shapes can achieve and 2) Does one want a smooth jawline connection between the chin and jaw angle area?
Case Study: This 35 year-old male wanted a more defined jawline but he did not want it to look too big or unnatural. In essence he did not want it to be obvious that he had surgery. Thus a relatively modest custom jaw implant was designed to make his chin more square and provide some increased angularity to the jaw angles.
Under general anesthesia the custom jawline implant was placed through a three-incision technique. (anterior submental skin and posterior bilateral intraoral mucosal incisions) The implant was placed from front to back through a subperiosteal tunnel under the intervening mental nerves. The one-piece wrap around implant was secured at the chin and jaw angles by a single 1.5mm microscrew at each location.
Six weeks later all of his swelling had resolved and most of the final result could be appreciated. His jawline had a greater chin prominence and a stronger jaw angles. But it looks perfectly natural and still fits his face well.
A custom jawline implant does not have to be big to be effective. Small to modest sized jaw implants can produce a nice improvement to the lower face
1) Having a visible and more defined jawline is a frequent aesthetic request amongst men
2) A more stronger and more defined jawline does not always mean that it is substantially bigger, just more evident chin and jaw angle areas.
3) A custom jawline implant offers the only jawline augmentation procedure that creates a stronger chin and jaw angles with a smooth connection between them.
Augmentation of the jawline can be done by a variety of implanted materials. While recent trends in plastic surgery have focused on using injectable fillers and fat for many forms of facial augmentation, this is not a particularly successful treatment strategy for the jawline. Most jawline shape changes, particularly in men, call; for a more defined and angular definition which soft injected materials can not usually create. Such external changes require a firm push from the bone surface using firmer implanted materials.
While jawline augmentation has traditionally been done by preformed chin and jaw angle implants, some patients need greater dimensional changes than three separate implants can provide. This is where the expanding role of custom implants made from the patient’s 3D CT scan has become extremely useful. A one-piece wrap around jawline implant unites changes to the chin and jaw angles for a more complete and smooth jawline effect. Such custom jawline implants can be made into virtually any size and shape although great preoperative consideration must be given to its design for who it may affect the patient’s external appearance and desired facial aesthetic goals.
Surgically placing a one-piece wrap around jawline implant can be challenging. It requires a three incisional approach, one anterior and two posterior. The anterior incision may be either intraoral or external below the chin. Subperiosteal tunneling is done between the incisions to make a path for the implant to slide into place. I always try to place such jawline implants in one piece but this is not always possible or advised. The size of the jaw angles on the implant determine whether it can be folded and safely passed under the mental nerve from the anterior incision or not. When the jaw angles are too big it is best to split the implant in half through the chin segment. Then it is passed from back to front so the smaller chin segment can go underneath the mental nerves without too much stretch on them. The implant is then reunited in the midline and secured together with small titanium microscrews as seen in this picture.
While a custom jawline implant may be made as a single piece, this does not mean that it needs it be placed that way. Screw fixation of the implant segments, like a bon fracture, allows it to become once again as a single unit. With only two pieces this is one puzzle that is easy to solve.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.