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Archive for the ‘jaw angle implant’ Category

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

Case Study – Three-Piece Total Jawline Augmentation

Tuesday, September 6th, 2016

 

Background: Total jawline augmentation refers to changing the entire look of the mandible. This could mean that the entire jawline has to be changed that can only be done by a custom wrap around jawline implant. But not everyone needs augmentation of all areas of the jawline. Many patients just need to change the three ‘corners’ of the jaw, the chin and the two jaw angles.

A three-piece approach to total jawline augmentation most typically refers to the use of chin and jaw angle implants. A variety of chin and jaw angle implant styles and sizes now exist that can meet the dimensional needs of most patients. Jawline implants can add width, vertical length and horizontal projection. But the one dimension that no jawline implant can achieve is a shortening effect.

The one dimension in jawline reshaping that requires a reductive approach is vertical chin shortening. Many very recessed chins are actually vertically long because of the backward rotation of the entire mandible due to an underdeveloped ramus. While a chin implant can add the necessary horizontal projection, it can not make it shorter. Placing the chin implant high to try and create this effect will lead a fullness under the augmented chin and will not really make it appear vertically shorter.

Case Study: This 38 year-old male presented for improvement in the shape of his jawline and lower third of his face. He had a recessed and long and a narrow jawline shape.

Total Jawline Augmentation result front view Dr Barry Eppley IndianapolisUnder general anesthesia he initially had a sliding genioplasty performed with a 10mm forward movement 5mms of vertical shortening. Bilateral jaw angles implants were placed that primarily added 7mms of width but only 1mms of vertical lengthening.

Total Jawline Augmentation result side view Dr Barry Eppley IndianapolisTotal Jawline Augmentation results oblique view Dr Barry Eppley IndianapolisHis result shows the impact of widening his jawline but also shortening it anteriorly. This combination creates a broader and more masculine appearing lower third of his face. While the chin change significantly improved his profile, it is the jaw angles that added the most to his front and three-quarter views.

He had a long chin due to its recessed position. While a chin implant could have been used that would have maintained his vertically long face and would also have required the jaw angles to be vertically elongated as well. To help shorten his overall face a sliding genioplasty is a better choice because it can shorten the lower third of his face on the front part of the jaw.

Highlights:

1) Total jawline augmentation refers to the three corners, the chin and the two jaw angles.

2) A sliding genioplasty with jaw angle implants is a three piece approach to total jawline augmentation.

3) A sliding genioplasty is better than a chin implant when the forward movement of the chin needs vertical shortening as well.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Jaw Angle Implants after Mandibular Osteotomy

Thursday, August 25th, 2016

 

sagittal split manidbular osteotomyBackground: The sagittal split mandibular osteotomy (SSRO), most commonly used for lower jaw advancement, is one of the most ingenious of all the craniomaxillofacial osteotomies. Splitting the ramus of the mandible longutudinally into two vascularized bone segments is a technical marvel. It allows the distal tooth-bearing portion of the lower jaw to be moved forward while leaving the proximal TMJ-containing bone segment in place. This maintains good bone contact that is fixed together and heals without creating a bone defect.

While the bones segments of a sagittal split mandibular osteotomy do maintain the shape of the jaw angle during the procedure, the jaw angle shape can adversely change as it heals. Some bony resorption of the jaw angle is not rare as the proximal bone segment not only becomes thinner afterwards but probably suffers some degree of devascularization in some cases. This resorption pattern can make the back of the jaw look thinner with a higher jaw angle shape externally.

Such jaw angle shape deformities after a mandibular osteotomy is more prone in thin jaws, inadvertent fracture patterns (aka ‘bad splits’) and repeat sagittal split procedures. The best diagnosis of the jaw angle shape is a from a 3D CT scan where the two sides can be compared in both frontal and side views.

Case Study: This 22 year-old female had a history of orthognathic surgery consisting of a LeFort I, mandibular sagittal split osteotomies and a sliding geniplasty several years previously. She felt that her lower face was too thin and lacked any definition as well has still had inadequate chin projection.

Vertical Lengthening Jaw Angle Implants after Sagittal Split intraop Dr Barry Eppley IndianapolisUnder general anesthesia she had a total jawline augmentation done using standard implants. An anatomic extended chin implant of 8mms projectionwas placed through an intraoral incision. Then using new preformed vertical lengthening jaw angle implants (7mms lengthening and 5mms width), they were inserted intraorally through her previous incisions. The jaw angle implants were placed below the existing bone plates used to secure the mandibular osteotomies and posed no problems for their placement. The jaw angle implants were screwed into placed with a percutaneous screw fixation technique.

Simulated Vertical Jaw Angle Implant effects oblique view Dr Barry Eppley IndianapolisSimulated Vertical Jaw Angle Implant effect Dr Barry Eppley IndianapolisThe goal of the jawline enhancement was to create a more visible jawline both at the front and back of the jaw. By bringing the chin further forward and rotating the jaw angles downward a more distinct lower jaw shape is created as seen in this preoperative predictive imaging.

Highlights:

1) Loss of the jaw angle shape can occur after sagittal split osteotomies due to bone resorption.

2) Jaw angle implants can either restore or augment the shape of the jaw angle.

3) Whether the jaw angle implants should be standard or custom made depends on how much bone resorption has occurred and the amount of bony asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jaw Angle Implant after BSSRO Surgery

Sunday, July 17th, 2016

 

Background: The most common method of corrective lower jaw surgery is the sagittal split ramus osteotomy. (BSSRO) While initially described over half a century ago, it remains the cornerstone of lower jaw repositioning surgery. It is an incredibly clever oseotomy design that I still consider a marvel of craniofacial bone surgery and remains technically challenging to perform even after having one the operation for decades.

sagittal split manidbular osteotomyLongitudinally or sagittally splitting the mandibular ramus into proximal and distal segments allows the toothbearing portion (distal segment) to be moved independently of the proximal (jaw joint containing) segment. Once the teeth are set into the desired bite, the overlapping proximal and distal segments are put back together allowing for maximal bone contact to expedite bony healing.

But the proximal mandibular segment, which provides the shape to the jaw angle, is largely stripped of its soft tissue attachments in the execution of a BSSRO. This partially devascularizing effect can cause the shape of the bone to undergo some postoperative remodeling. This can cause the shape of the jaw angle to change. While it doesn’t always occur it is probably an under reported aesthetic bony change.

Case Study: This 35 year-old female had a prior history of a mandibular osteotomy to correct a malocclusion accompanied by a sliding genioplasty. While this gave her a good bite it left her with facial asymmetry which was most pronounced at the jaw angle areas. She did have treatment with liposuction and fat grafting into the right jaw angle but this did not improve her facial asymmetry adequately.

Custom Jaw Angle Implant for Asymmetry Dr Barry Eppley IndianapolisIt was decided to perform bilateral jaw angle surgery with liposuction to the right jaw angle (to remove the injected fate) and augment the left jaw angle with a custom jaw angle implant. A 3D CT scan was used to both evaluate and design the left jaw angle implant.

Jaw Asymmetry Surgery result front view Dr Barry Eppley IndianapolisUnder general anesthesia the right jaw angle soft tissues underwent small cannula liposuction from an incision behind the earlobe. The custom jaw angle implant was placed in the left side through an intraoral incision and secured with a single 1.5mm microscrew. The combination of the right jaw angle liposuction and the left jaw angle implant improved her facial symmetry.

Deformations of the jaw angles can occur from the BSSRO procedure. The bone may heal perfectly but there can still be a change in the shape of the jaw angle due to bony resorption. Restoration or enhancement of jaw angle shape can be done with an implant. Whether the jaw angle implant would need to be custom or not depends on the degree of  bony jaw angle deformity.

Highlights:

1) Jaw angle deformation and asymmetry is not rare after sagittal split mandibular osteotomies.

2) Asymmetry of the jaw angles is best assessed by a 3D CT scan to develop an accurate appreciation of their bony differences.

3) A custom jaw angle implant is the best method to correct bony angle asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Angle Implants vs Injectable Fillers Volume Effects

Saturday, July 2nd, 2016

 

Jaw angle implants have become more recently recognized as an essential part of jawline augmentation. While much focus has historically been on the front protruding part of the jaw through chin augmentation, it is now recognized that the chin represents just a part of the total lower facial effect.

While jaw angle implants have been around for several decades they have been limited to an implant style that only provides width to the ramus of the mandible. While this has a beneficial role in some patients, many jaw angle deficiencies are as much vertical if not more so than just width. Lengthening the jaw angle and creating a more obvious angularity to the back part of the lower jaw has some major aesthetic benefits.  This has been remedied today with more vertical lengthening jaw angle implants. Injectable fillers have also been used to create this effect with variable success. But it is an accepted ‘trial’ method for some patients to determine if such changes would be perceived as beneficial.

When it comes to jaw angle augmentation does an injectable filler really create the same effect as an implant? And if it does how does it compare volumetrically?How does the volume of an injectable filler compared to the displacement effect caused by a solid implant? In other words, how much injectable filler does it take to create the same effect as that of an implant?

Comparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would be equal to the volume of the implant. Using newer vertical lengthening jaw angle implants of its three available sizes, their weights in grams and volume displacement were as follows:

JAW ANGLE IMPLANTS

Small              3.65 grams     1.6 ml

Medium        7.54 grams     2.7 ml

Large            14.98 grams    4.2 ml

Jaw Angle Implants vs. Injectable Fillers Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to jaw angle implants can be directly done. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to less than half of a small jaw angle implant. Larger jaw angle implants more directly compare to more than two to three 1.5cc syringes of Radiesse.

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants.

Dr. Barry Eppley

Indianapolis, Indiana

Bony Overgrowth of Jaw Angle Implants

Sunday, June 26th, 2016

 

Jaw angles implants are becoming increasingly popular for their jawline augmentation effects. Different styles of jaw angle implants allow for a variety of posterior jawline effects from widening, lengthening and combinations thereof. Like a chin implant they are placed in the subperiosteal submuscular position at the back of the jaw.
The difference in jaw angle implants, compared to almost any other site-specific facial implant, is their size. They are comparatively large and are placed under the largest muscle in the face, the masseter muscle. It is also a muscle that has a lot of repetitive activity as it is responsible for both its chewing effects as well as aiding in moving the lower jaw.
Bone Overgrowth Jaw Angle Implants Dr Barry Eppley IndianapolisJaw Angle Implant Bony Overgrowth Dr Barry Eppley IndianapolisHaving done many jaw angle implants and seeing 3D CT scans of their position on the bone, I have noticed a very interesting finding. Many jaw angle implants will have developed bony overgrowth over their edges. It does not matter whether the implant is composed of silicone or Medpor material, it occurs on both materials. It is a frequent finding on 3D CT scans over jaw angle implants or the jaw angle portion of a total wrap around jawline implant.
The bony overgrowth that develops is very thin and has the consistency of an eggshell. It easily flakes off the implant and is similarly easily removed from its attachment to the side of the jawbone from where it grew. it is interesting that it develops even on smooth silicone implant surfaces.
Bony overgrowth is seen in other facial implants and is a well observed finding in chin implants. It is commonly seen in chin implants that have developed some passive settling into the bone with new bone growing up along its side. While such implant settling is seen in chin implants I have not observed in jaw angle implants.
The source of the bone growth is undoubtably from the periosteum on the underside of the large masseter muscle’s inner surface that has been raised up off of the bone. This is a potent source of bone stimulation and growth.
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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