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Archive for the ‘jaw angle reduction’ Category

Mandibular Gonioplasty – Jaw Angle Removal vs. Jaw Angle Reduction

Wednesday, April 13th, 2011

The shape of the lower jaw has an influence on the appearance of one’s face. Besides the shape and prominence of one’s chin in the front, the other important jaw features are that of the paired angles in the back. The more prominent or square the jaw angles are, they can enhance the masculine features ofa man and can give the impression of strength and confidence in a woman. When the jaw angles are too prominent, however, the jaw can be disproportionately wide as compared to the rest of the face. This may create a very square-shaped face and is the motivation for aesthetic jaw angle modification surgery, also known as a gonioplasty. (jaw angles are also referred to as the gonial angles)

Jaw angle bone modification is done to soften the face and make for a less square or more oval-shaped face. Some may call this creating a more feminine jawline and this is certainly true for a woman considering the procedure. Fewer men undergo gonioplasties because the square jaw is a desired masculine feature but there are some men whose jaw angles are exceptionally prominent who want modification as well.

When considering jaw angle modification, it is extremely important that one understand that there are different techniques for doing it…with different aesthetic outcomes. The traditional and most commonly used method is jaw angle removal surgery. This is always referred to as jaw angle reduction but this is a misnomer. Reduction implies the bony angle is preserved but reduced. In reality, the entire jaw angle is simply cut off or removed. From incisions inside the mouth, the junction of the back part of the jaw and the lower border of the jaw is essentially cut off. This not only softens the jaw angle but also raises the line of the jaw from front to back.

For many women, the elimination of the jaw angle (and raising the height of the back part of the jaw up to a horizontal level of the mouth) is aesthetically advantageous because it is a feminizing procedure. It is also the most effective way to thin the width of the face (jaw angle to jaw angle) because the full-thickness of the jaw bones in this area are removed. Given that that each jaw angle is 1 cm or more thick, one can narrow the lower facial width by up to 2.5 cms. For men, however, the total loss of the jaw angles may be aesthetically advantageous and must be carefully considered. I have consulted more than one man who wanted jaw implants to replace jaw angles that have been cut off.

The other technique for gonioplasty is true jaw angle reduction. In this technique, the jaw angles are not cut off but thinned by burring reduction. The shape of the jaw angle is preserved but the bone is thinned. Its advantage is that the jaw angle is not eliminated or raised but its disadvantage is that it can not achieve as much narrowing. This is because the full thickness of the bone is not removed but thinned. This changes the amount of transfacial width reduction at the jaw angles to maybe 1 to 1.5 cms.

In lower facial gonioplasty, the two available techniques are removal (excisional gonioplasty) and reduction. (reduction gonioplasty) Their effects on the jaw angle and the amount of width reduction are different. The use of the term ‘jaw angle reduction’ is often misunderstood and may lead to undesired jaw shape outcomes if done in a standard fashion for every patient. This may lead to some unhappy patients seeking jaw angle implant reconstruction later.

Dr. Barry Eppley

Indianapolis, Indiana

Risks of Jaw Angle Reduction Surgery

Saturday, December 11th, 2010

A recent report out of China was that of a death due to plastic surgery. What was most significant about this report, besides the obvious tragedy, is the procedure which ultimately resulted in the patient’s demiss. While deaths from plastic surgery procedures are extremely uncommon and have been reported in the past, most involve a cosmetic operation done on the body.Such lethal occurrences are even more rare in plastic surgery of the face.

A young prominent 24 year-old female (she was an aspiring pop singer who was on China’s equivalent of ‘American Idol’) died in November while undergoing ‘facial-bone grinding surgery’. According to the report, her jaw bleed uncontrollably at some point in the operation which lead to it accumulating in her throat. This blocked her ability to breathe and she subsequently suffocated and died.

What was this ‘facial bone grinding surgery? This does not sound like a very common cosmetic facial procedure and why would anyone have their facial bones ground on? While I don’t know any of the details of this specific surgery, it could only be that of a jaw angle reduction procedure. While very rarely requested or done in Caucasian patients and in the U.S., it is actually a fairly common cosmetic facial procedure in the Asian patient and in countries such as Korea and China. In the desire to have a more slim and less broad face, narrowing the prominent jaw angle is one facial procedure that helps achieve that goal. It is not usually done by grinding or burring of the bone but by actually cutting off the angle of the jaw bone with a saw. One of the known potential complications, albeit rare, is to inadvertently cut one of the large blood vessels to the surrounding masseter muscle which envelopes the bone. This may cause a lot of bleeding but it isn’t usually a lethal complication.

How is it possible for this young lady to have suffocated from the bleeding during her surgery? This could only have happened from the type of anesthetic she was having. Always in my hands, this isan operation that is done with the patient fully asleep (general anesthetic) and having their airway protected by an endotracheal tube. This breathing tube not only makes sure that one’s airway does not get blocked but also prevents any fluid that would enter the throat from being allowed to get into the lungs. For her to have suffocated from the bleeding, she must not have had a breathing tube in a place. This also means she was done under some form of local or sedation anesthesia…an almost unthinkable notion for this kind of surgery. Besides patient comfort, a general anesthetic with a protected airway also helps ensure patient safety should bleeding events like this one should occur.

Like many tragic outcomes from cosmetic procedures, close inspection of the story often bears out that uncommon and unusual approaches were being done. Taking shortcuts in cosmetic surgery should never over ride patient safety measures.

Dr. Barry Eppley

Indianapolis Indiana

Facial Bone Reduction Surgery

Monday, February 1st, 2010

Changing one’s bony prominences is the primary method for altering the shape of the face. The face is composed of a variety of bones which have convex and concave contours. The external appearance of the face is highly influenced by the convex bone contours. From the brow bone down to the long curvilinear shape of the mandible, there are numerous key bony projection points. (e.g., cheeks, chin, jaw angles)

Most commonly, a variety of plastic surgery operations exist to enhance or increase their projections. Chin, nose, cheek and jaw angle implants are prime examples. It is almost always easier to increase facial bone projection by adding to the bone rather than actually moving the bone.  There are also, however, operations that work in reverse…to reduce or deproject these very same prominences.

Facial bone reductions are not as well known and are less commonly done. Unlike augmentations, facial reduction procedures require modification or shortening of the bony prominences. While some can be shaved down, others require actual cutting off or out of bone sections to change the amount of bony projection.

Brow bone reduction is requested when the brows have a very prominent or ‘Neanderthal’ appearance. Mainly this procedure is done in men and in male to female conversions. (facial feminization surgery) This must almost always be done through a frontal hairline or scalp incision. In some cases, the brow bone may be simply burred down but this is unusual. The underlying frontal sinus occupies much of the width of the brow bone so the overlying bone is quite thin. Only if one is modifying the tail of the brow can it be just burred down. The outer table of the frontal sinus must be removed, reshaped, and then put back with tiny plates and screws. The scar from the incisional approach is the key decision in deciding to undergo this operation.

Cheek reduction is about modifiying the front edge of the cheek bone and its arched form back to where it attaches to the temporal bone. Most patients that want cheek reduction are often Asians in an effort to improve their wider face appearances. A vertical bone cut is made through the body of the malar bone and a wedge of bone is removed. The reduced cheek bone is then attached to the maxilla with a four-hole plate and screws. To get the more posterior part of the arch to move inward, the thin attachment of the posterior part of the zygomatic arch is cut with an osteotome and allowed to move inward (by muscle pull) without the need to secure it.

Nasal reduction is achieved by conventional rhinoplasty techniques. A significant part of a nasal hump is actually cartilage and not bone. The key in reductive rhinoplasty is not to overdo it, creating a saddle nose or pinched upper and middle vault appearance. This can result in nasal airway breathing difficulties. When it comes to helping a face look less wide and more sculpted, the nasal dorsum often is better elevated and not reduced.

Chin reduction is done by burring down the genial prominence. While this bone area is simple to get to through a submental incision, chin reductions are notoriously prone to cause soft tissue problems if not done correctly. This is the only facial bony prominence where the soft tissue does not just ‘snap back’ over the bone. If the excess skin and muscle is not removed and readapted back to the reshaped bone, it will sag resulting in the classic ‘witch’s chin deformity. Also, unlike chin bone advancements which can be brought forward 10 to 12 mms or more, retropositioning of the chinbone can not be done as dramatic and is more in the range of 4 to 6mms at best. Going back further than that can have adverse effects on the neck causing undesired fullness.

Jaw angle reduction is most commonly done in Asians like cheek reduction. Through an incision inside the mouth, the angle of the jaw is blunted by an oblique bone cut removing the prominent tip. How much of the tip or angle area is removed is a matter of intraoperative judgment. There is a fine balance between removing too little and completely having no angle at all. A nearly straight line from below the ear to the chin is not desireable either. This is the most uncomfortable of all the facial bony prominences to reduce because the large master muscle must be raised, causing considerable swelling after also.     

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Surgical vs. Non-Surgical Jaw Angle Reduction

Friday, October 3rd, 2008

Jaw reduction strives to narrow the lower-third of the face, particularly that of the lower jaw and its muscle attachments. There are several techniques for jaw reduction, some surgical and others non-surgical. Jaw reduction is most common in Asians where there is a societal preference for a slender jaw profile. This is in contrast to Causcasians which are more deficient in this area and augmentation is needed rather than reduction.

One form of jaw reduction involves surgical reduction of the mandible  or lower jaw angle area. Done through an incision inside the mouth, the jaw angle (junction of the back part of the jaw and the lower border of the jaw) is essentially sawed off. This changes the sharp acute angle of the jaw to a more round one. This softens the jaw angle and raises the line of the jaw from front to back. The bone cut can be extended from the jaw angle forward to about the middle of the body of the jaw for greater narrowing. Another bony reduction option is an outer corticotomy. Rather than just saw off the entire jaw angle, which can really blunt the angles and cause loss of soft tissue support, is to remove just the outer cortex of the angle area. Done lije a reverse sagittal split osteotomy, this will thin out the jaw angle are but without blunting the angle.

One thing that bony jaw angle reduction of any method does not do is correct for the thickness of the muscle over the bone.  It is not really possible (or desireable if you are the patient) to surgically thin out the muscle without causing a lot of pain and causing long-term restriction of mouth opening. Therefore, the effectiveness of jaw angle reduction will be more or less dependent on the how much the bone of the jaw causes the fullness of the jaw angle. That being said, bony jaw angle reduction will always make a visible external difference.

Non-surgical jaw angle reduction means Botox® injections. While this muscle paralyzing drug initially seems like it would not work for long-term muscle reduction (atrophy), it has been shown that it actually does. The dose of Botox® is fairly high for each side ( about 40 to 50 units), and it must be repeated every 4 months or so for up to a year or longer, but I have witnessed the masseter muscle actually get smaller over time. Why the muscle shrinks when it is partially paralyzed (chewing function is not affected)  is not known and the next question is….will it stay smaller long after the Botox® injections are stopped. Proponents of this injection technique say that it does but  long-term clinical studies have never been reported as of yet.

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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