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Archive for the ‘jaw angle implant’ Category

Case Study – Dermal Graft for Jaw Angle Asymmetry

Tuesday, February 14th, 2017

 

Background: Asymmetry of the lower third of the face is common. While there can be a soft tissue component to it, more times than not it is caused by asymmetry of the bone. the most common location for jaw asymmetries is in the angle area. The mandibular ramus is the L-shaped portion of the jaw and is prone to differences between the two sides in length and/or width.

Jaw angle asymmetry is best appreciated from the front view. Patients particularly notice it in pictures where the face becomes ‘frozen’ and is most easily seen. But because everyone of us knows our faces so well (and more so today because of smart phones and selfies) patients can see it even when others can’t.

The treatment for a jaw angle symmetry due to a deficiency is an implant. Provided the location is known and the implant is the right shape and size, good correction can be expected. But not everyone likes the concept of an implant so alternative options may be considered.

Case Study: This 32 year-old female had a modest jaw angle asymmetry with a deficiency on her left side. The inferior border along the angle lacked the fullness and jawline that the opposite side had. She preferred to use a more ‘natural’ material rather than an implant.

Dermal Graft for Jaw Angle Asymmetry Correction Dr Barry Eppley IndianapolisLeft Jaw Angle Dermal Graft Implant for Asymmetry Dr Barry Eppley IndianapolisUnder general anesthesia an intraoral approach was used to access the left jaw angle bone. Using allogeneic dermis (Alloderm), a 1.5mm thick section was layered into a thicker implant and sutured together to create a linear graft for the inferior border of the jaw angle. It was inserted and laid along the border. No form of fixation was used.

Jaw Angle Asymmetry Correction result Dr Barry Eppley IndianapolisHer 6 month result showed better jaw angle symmetry and an apparently stable result without resorption.

An allogeneic dermal graft would not ordinarily be a preferred facial bone augmentation material. It is a soft tissue augmentation material that purportedly is integrated into the recipient site and replaced by natural tissue. (scar) In my experience it more often behaves like an implant and becomes a well tolerated tissue filler with some fibrovascular ingrowth. For minor facial bone asymmetries where an implant is not preferred, these dermal products can be an option to consider.

Highlights:

1) Lower facial asymmetry is most commonly caused by a bony asymmetry of the jaw.

2) Jaw angle asymmetries can be treated by a variety of implant materials placed on the bone.

3) For patients wary of synthetic implants on the jawline, an allogeneic dermal graft can be used for smaller jaw asymmetries.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sliding Genioplasty for Chin Implant Replacement

Monday, February 13th, 2017

 

Background: Chin implants in females is a common lower facial reshaping procedure. While they add desired amounts of horizontal projection and improve the facial profile, the extended wing designs of today’s chin implant designs can have adverse effects on they look in the front view. While the extensions on the implants are designed to create a natural transition into the jawline bone without a visible stepoff, they add chin width to do so. While this is rarely an issue in men, it can be more frequent aesthetic problem in women.

Women seeking an improved jawline have a different aesthetic goal than men. They do not necessarily seek an angular jawline with visible corners.  (some women may bit not the majority) Rather they usually desire a V-shape to their jawline with a smooth linear line from front to back. As part of that aesthetic goal the chin must be narrow and may even have a more pointy chin or smaller V-shape appearance. This is in contradiction to the look that many chin implant styles give to the augmented chin.

Case Study: This 35 year-old female had a prior history of having chin augmentation done using a Medpor chin implant of 6mm projection placed through an intraoral approach. She never liked the result as it gave her a wide and boxy chin. This did not fit her small petite face well. While it provided adequate horizontal projection, it made her chin too wide and too vertically long. She also developed some lower lip sag and excess tooth show.

Medpor Chin Implant Removal and Sliding Genioplasty Replacement intraop Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result front view Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia her indwelling Medpor chin implant was removed intraorally. To do so it had to be sectioned into multiple pieces and required the removal of 6 titanium screws. It was replaced by a sliding genioplasty that was brought forward 6mm and vertically shortened 3mms. A mentalis muscle resuspension and vestibuloplasty were performed to help with her lower lip sag. Concurrently, vertical lengthening jaw angle implants were placed through posterior vestibular intraoral incisions. The implants added 7mm of vertical length and 3mms of width.

Any form of chin or jawline augmentation must take into consideration the differences be tween male and female jawline shapes as well as the patient’s aesthetic goals. Even a ‘simple’ chin augmentation must take this into consideration as the operation may be a technical success but an aesthetic failure. (as this case illustrates) The entire jawline from front to back must also be considered in an effort to create an improved jawline that fits the patient’s face.

Highlights:

1) Chin implants in females create horizontal projection but often at the expense of too much chin width.

2) A sliding genioplasty can replace a chin implant by providing horizontal projection but with a more narrow chin width.

3) Jaw angle implants can create vertical lengthening with a sliding genioplasty to give a more defined jawline in females.

Dr. Barry Eppley

Indianapolis, Indiana

Vertical Lengthening Jaw Angle Implants

Sunday, February 12th, 2017

 

While jaw angle implants have been around for over 25 years, they only recently have become more popular and in higher demand for jawline enhancement. Offering augmentation to the often overlooked back part of the jaw, they add dimensions to the lower third of the face that can be primarily seen in front and oblique facial views. This is in contrast to chin implants which create their most profound effect in the side or profile view.

Based on how they impact the face it can be appreciated that the combination of chin and jaw angle implants creates a true 3D total jawline effect through a three-point triangulation effect.

Like many other facial implants, jaw angle implants also come in different styles. Fundamentally there are two different jaw angle implant types, widening (lateral) and vertical lengthening. This distinction is critical as they create profoundly different effects on the jawline.

The original and still commonly used jaw angle implant is the widening version. The implant sits on the outer aspect of the posterior-inferior ramus and gives the jaw angle more width. This is suitable in the patient who already has adequate length to their angles, has a normal mandibular plane angle and just needs augmentation to their natural bony width.

While appropriate for many patients, widening the jaw angle does not work well for everyone. An overlooked aesthetic jawline diagnosis is the patient who has high angles. They may also be too narrow but the jaw angle is almost at the level of the earlobe. This is too high of a mandibular plane angle and requires vertical lengthening. Placing widening angle implants in the high mandibular plane will just make the face look wider/fatter and will not create a more defined jaw angle appearance.

Vertical lengthening jaw angle implantsVertical Lengthening Jaw Angle Implants Dr Barry Eppley IndianapolisA newer style of vertical lengthening jaw angle implants has been developed for the high angled jawline. In this implant style a portion of the implant sits below the existing angle bone. By dropping down the angle it not only gives it more visible length but also adds width as well. These two dimensional changes put together into an angular shape creates a much more visible jaw angle and fullness to the back part of the jawline.

Most patients who have a short chin usually have a higher jaw angle position. This is a natural part of the L-shape to the lower jaw and the way it develops from its growth center. A chin implant with vertically lengthening jaw angle implants is the best combination for total jawline augmentation in these patients.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Stacked Jaw Angle Implants

Sunday, January 8th, 2017

 

Jaw angles implants are designed to add size and shape to the mandibular ramus area. They are a companion and complement to the more commonly performed and well known chin implant. Together chin and jaw angle implants create a complete jaw augmentation approach.

While selecting the style and size of chin implants is fairly easy, doing so with jaw angle implants is not. Since the chin is a projecting structure on the edge of the jaw, the amount of horizontal projection is frequently the most important dimensional consideration. This is both easy to see, measure as well as perform computer imaging. Jaw angle implants, however, are not an edge enhancement procedure. Rather they provide augmentation to the side of the jaw/face where measurements and even computer imaging is harder to do in a reliable fashion.

Because of the more imprecise nature of jaw angle implant size selection, it is very helpful to be prepared during surgery with multiple implant sizes. Most of the time standard sizes will work (small, medium and large) but this is not always the case. How an implant looks in place can be less than what one would anticipate and there is always the issue of asymmetry which is very common in the jaw angle area.

stacked-jaw-angle-implants-technique-dr-barry-eppley-indianapolisIf necessary it is always possible to stack jaw angle implants together to create the desired augmentation effect. Unlike many other facial implant types, angle implants fit together fairly well… a little bit like nesting dolls. Some trimming does need to be done but the implants can be stacked fairly securely. This will increase the width of the jaw angle augmentation over what any one single implant can do.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Older Female Jaw Angle Implants

Saturday, January 7th, 2017

 

female-strong-jawline-dr-barry-eppley-indianapolisBackground: The strength of the lower jaw is a known favorable feature for a male. But it has become increasingly desired and requested for women as well. Partially spurned on by various well known celebrities and actresses’ jaw shapes, younger women are seeking stronger jawlines as well.

An important part, and until recently overlooked, of a well defined jawline is the jaw angles. When patients refer to a ‘stronger jawline’ they are usually referring to the jaw angle area. A well defined and prominent jaw angle is one that is clearly seen from the front view and often creates more of a V-shape to the jawline. While once considered more masculine, a female with more prominent jaw angles are now seen as youthful and atractive.

One unexpected but favorable effect of jaw angle augmentation is that it provides a lift along the jawline. Making a stronger jaw angle requires increased soft tissue coverage. This recruits tissue from the neck to cover the increased bony prominence. This can have a favorable effect in the older patient who has developed loose skin along the jawline and posterior neck.

Case Study: This 61 year-old female was to undergo a variety of facial rejuvenation procedures. One of her requested procedures was jaw angle augmentation. She wanted more defined jaw angles and v-shaped jawline. She previously had a facelift.

female-jaw-angle-implants-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia, she had medium widening jaw angle implants placed through posterior intraoral incisions. The implants were placed under the masseter muscle, snuugly fitting up against the existing bone angle posterior and inferior contour.

cw-jaw-angle-implants

A more sharply defined jaw angle has both a jawline reshaping effect and a lower facial rejuvenative influence in older patients. Even in the older female patient who has already had a facelift, a stronger jaw angle adds to a rejuvenated jawline.

Highlights:

1) Jaw angle implants add shape and definition to the back part of the jaw/lower face.

2) Females are having an increased interest in the shape and definition of their jawline.

3) In older females a stronger jaw angle can fill out loose skin and give a bit of a facial rejuvenative effect.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Jaw Angle Augmentation Fillers vs Implant

Monday, December 26th, 2016

 

Augmentation of the facial skeleton has historically been done through the placement of preformed implants. The past decade has seen the emergence of a variety of injectable materials to create soft tissue volume augmentation. These have included a large number of synthetic fillers as well as autologous fat. As their use has become more common and pervasive throughout aesthetic surgery, the injectable approach has been applied to every conceivable aesthetic facial need including augmentation of the bony cheeks, chin and jaw angles.

An injectable filler can be used for jaw angle augmentation. It does not usually produce the same result as a well selected jaw angle implant as it can not create angularity and sharper definition with the push of a soft material like fillers or fat. Thus injectable fillers for jaw angle augmentation is often done as a test or trial or are sometimes performed as a convenient opportunity at the time of other facial surgery using fat injections.

jaw-angle-implants-vs-injectable-fillers-dr-barry-eppley-indianapolisBut beyond that of a trial, the use of injectable fillers as a long-term method of jaw angle augmentation is compromised by economic issues. When one compares the volume of an injectable filler to an actual jaw angle implant (in this picture 1.5cc of Radiesse to a medium vertical lengthening jaw angle implant) the tremendous discrepancy in its volume/size can be seen. By comparing weights alone it can be seen that it would take more than 5cc to 7cc of a filler to match the volume created by an implant.

Because of their long-term cost issues, injectable fillers are a short-term approach to jaw angle augmentation. This is not only because they are not permanent but the sheer cost of trying to replicate an initial jaw angle implant effect.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Three Implant Jawline Augmentation

Thursday, October 27th, 2016

 

Background: Creating a stronger male jawline can be done by a variety of methods, most of which are done by permanent implants. While many plastic surgeons still think that the approach to a better jawline comes from chin implant augmentation alone, that approach excludes any consideration of the back of the jaw which makes up two-thirds of its structure. A more contemporary treatment approach takes the whole jawline into consideration.

The traditional jawline augmentation approach uses three standard styles and sizes of facial implants. This include a chin and two jaw angle implants. The choices for chin implants are either a more commonly used anatomic or convex implant shape and a more square formed shape style. Jaw angle implants can be either a widening or vertical lengthening style. Historically only the widening jaw angle style was available but newer vertical lengthening styles offers a better option for those patients with high jaw angles.

The advantage of a standard three implant jawline augmentation are economy and time efficiency. Unlike a custom implant which requires a 3D CT scan and a month to design and manufacture, standard facial implants are available off the shelf and at a lower implant cost. The one aesthetic disadvantage is that the implants are not connected so there will be an indentation along the jawline between the chin and the jaw angles. For some patients this may not be an aesthetic detraction and may even be a desired effect.

Case Study: This 25 year-old male wanted a stronger jawline with a more square chin and wider jaw angles.

standard-chin-and-jaw-angle-implants-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia, a medium square chin implant was placed through a submental skin incision. Widening jaw angles of 7mms were placed through bilateral intraoral incisions.

three-piece-chin-and-jaw-angle-implants-result-oblique-view-dr-barry-eppley-indianapolisthree-piece-chin-and-jaw-angle-implants-result-side-vuew-dr-barry-eppley-indianapolisHis postoperative result showed a satisfied patient with a more defined jawline. The chin was more square and the jaw angles wider. The jaw angles even had a slightly more increased vertical length to them by a few millimeters.

As long as the patient can accept a non-connected jawline look through chin and jaw angle implant augmentation, the use of standard implants can be an effective total jawline augmentation approach.

Highlights:

1) Total jawline augmentation consists of increasing the dimensions of the its three main points, the chin and the two jaw angles.

2) A three implant approach to total jawline augmentation includes the use of a square chin implant and two jaw angle implants.

3) A three implant jawline procedure creates a three point augmentation with an intervening concavity of the body of the mandible.

Dr. Barry Eppley

Indianapolis, Indiana

Choosing Jaw Angle Implant Styles

Saturday, October 22nd, 2016

 

The development of new jaw angle implant styles has finally allowed augmentation of the back part of the jaw to get caught up with that of the chin. The jaw angles have been overlooked for a long time as implant styles and sizes of the chin have progressed. With the chin and jaw angle implant styles that are now available the entire jawline can be augmented in the properly selected patient.

widening-jaw-angle-implants-design-dr-barry-eppley-indianapolisWith newer jaw angle implant styles, it is important that the indications for their use are clear. Traditionally jaw angle implants really only provided width to the mandibular ramus. They were designed to sit on the bone on its natural shape, thus increasing its lateral projection. Making the jaw wider is an effective aesthetic strategy provided the mandibular plane angle is not too high. If the jaw angles are within 2 cms or lesss from the earlobe they would be considered high jaw angles. A high jaw angle that is made wider can potentially make the face look too full or chunky and not create a more defined and stronger jawline.

widening-jaw-angle-imlpants-3d-ct-scan-dr-barry-eppley-indianapoliswidening-jaw-angle-implants-in-high-jaw-angles-dr-barry-eppley-indianapolisThis is a 3D CT example of this exact mismatched jaw angle implant problem. This patient has very high jaw angles and a steep mandibular plane angle. While these widening jaw angle implants are reasonably well placed over the rami the patient developed an undesired facial appearance as the enhanced jaw angles remained too high.

vertical-lengthening-jaw-angle-implants-design-dr-barry-eppley-indianapolisNewer styles of jaw angles help vertically lengthen the lower border of the mandibular ramus to treat the high jaw angle patient. This is a very unique facial implant style as a portion of the implant sits off of the bone to create its effect. As much as one third of the implant does not sit on the bone. In lowering the jaw angle it becomes more visually defined and the lower face appears more filled out in the front view. Vertical lengthening of the jaw angle is the most assured way to create a more visible back part of the jaw as it effectively corrects a bone ‘deficiency’. (missing part of the jaw) However one must be careful to not over lengthen the mandibular ramus as it can also make the lower face look too heavy in the patient who has a normal mandibular plane angle.

vertical-lengthening-jaw-angle-implants-dr-barry-eppley-indianapolisThis is a 3D Ct example of jaw angle implants that provide vertical lengthening. A portion of the implant design is off the bone to both lower and make more prominent the jaw angle shape at the back of the jaw. This is the appropriate jaw angle implant style for the high jaw angle patient.

Jaw angle implants today come in both widening and vertically lengthening styles. Each style does add some of the opposite dimension as well. Widening angle implants can add a little vertical length based on how they are positioned. Conversely the design of the vertical lengthening implant has built in width that increases the more it lowers the jaw angle

custom-jaw-angle-implant-design-dr-barry-eppley-indianapolisLike all facial implants not every standard shape and size works well for every patient. Significant jawline asymmetry, postoperative orthognathic surgery bony changes of the ramus and aesthetic dimensoonal needs beyond standard sizes are all reasons to consider custom jaw angle implant designs.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Custom Jawline Implant

Sunday, October 16th, 2016

 

Background: While jawline augmentation is most commonly associated with men, it is gaining aesthetic significance in women as well. A strong jawline is historically associated with increased masculinity. Women are more associated with softer and more recessed chin positions and jawline shapes. But the contemporary female jawline is now desired to have a more definitive jawline with increased angularity particularly at the posterior jaw angle area.

The one jawline dimension that is the hardest to change in both men and women is that of its vertical dimension. Short of orthognathic surgery to correct a deep bite, vertical augmentation with implants is needed to lengthen the lower face. But no standard chin or jaw angle implant provides any substantial vertical elongation. And lengthening the entire jawline as a single unified structure by bony movement requires the chin wing osteotomy with its own set of aesthetic issues.

female-custom-jawline-implant-design-dr-barry-eppley-indianapolisCase Study: This 26 year-old female presented with a history of injectable fillers to her chin to correct a significant chin deficiency. Despite multiple ccs of filler she still had a horizontal chin deficiency. Equally pertinently is that her lower jaw was vertically short compared to the upper two-thirds of her face. A custom jawline implant was designed to both vertically lengthen her entire jawline from angle to chin as well as provide horizontal chin augmentation.

female-custom-jawline-implant-intraoperative-insertion-dr-barry-eppley-indianapolisUnder general anesthesia the custom jawline implant was inserted through an intraoral approach. Three intraoral mucosal incisions were used including an anterior one below the front teeth and two posterior ones behind the second molars. It was inserted as a single piece passing it under the mental nerves from the chin area back to the jaw angles.

female-custom-jawline-implant-fronjt-view-ddr-barry-eppley-indianapolisfemale-custom-jawline-implant-oblique-view-dr-barry-eppley-indianapolisHer immediate after surgery results showed a substantial improvement in the fullness of her lower face. Her chin has better projection and her jawline back to the angles was more visible and defined.

female-custom-jawline-implant-result-side-view-dr-barry-eppley-indianapolisCustom jawline implants in females can be done just as it is in men. The difference is that they are often smaller in overall size with less dimensional augmentation. Creating a sharper and more defined jawline, not necessarily a substantially bigger size, is their usual focus. The exception is in the vertically short jawline where the lower face is disproportionately smaller than the upper two-thirds. In these cases vertical jawline lengthening needs to be done and pull down and out the lower third of the face.

Highlights:

1) Custom jawline augmentation for women can be done as successfully as that in men.

2) For vertical lengthening of the jawline in women only a custom jawline implant will suffice.

3) Most women get smaller custom jawline implants which may allow for a complete intraoral placement approach.

Dr. Barry Eppley

Indianapolis, Indiana

Medpor Jaw Angle Implant Removal

Thursday, September 8th, 2016

 

There are only two materials of which jaw angle implants are made, silicone and Medpor. While there are material differences between the two as well as each offer their own styles and sizes, there are surgeon advocates for either jaw angle implant material. With the proper implant selection and good surgical technique both materials can produce good jaw angle augmentation results.

Silicone jaw angle implants have recently introduced new widening and vertical lengthening styles with various sizes. They now offer superior designs for today’s male and female jawline enhancement patients. But Medpor jaw angle implants continue to be placed and many have been inserted in the past.

Revision or removal of such porous Medpor facial implant materials is well known to be difficult due to the tissue ingrowth. What was once an initial biologic advantage turns into a surgical challenge should secondary implant manipulation be needed. Surgical opinions vary as to this surgical challenge and range from difficult to impossible to do. The ante goes up considerably in the jaw angle area which is regarded as the most difficult type of facial implant to place.

Having done many revisional jaw angle implant surgeries, I have had the opportunity to remove a lot of Medpor implants. Most certainly there are far more difficult than a silicone implant but they can be successfully removed. Care has to be taken in dissecting the capsule off of the masseter muscle and, in particular, the inferior border where branches of the facial artery can be inadvertently cut in stripping off the very adherent scar tissue. The implant material comes off the bone the easiest probably because the underlying bone can be safely used as a fulcrum.

medpor-jaw-angle-implant-removal-dr-barry-eppley-indianapolismedpor-jaw-angle-implant-removal-fragmented-dr-barry-eppley-indianapolisIt is fairly uncommon to ever remove the jaw angle implant in a completely intact state. Far more commonly the material needs to be segmentalized. Interestingly Medpor material becomes somewhat softer after implantation due to the tissue ingrowth. Thus it often breaks apart during removal.

I have yet to see Medpor jaw angle implants, or any Medpor facial implant, that could not be removed in its entirety. But it can be traumatic to the tissues and the postoperative swelling from doing so may be greater than that seen during their initial placement.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

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.

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