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Archive for the 'jawline implant' Category
Background: Facial beauty is well known to be highly influenced by proportions and symmetry. Dividing the face into thirds, in either frontal or side views, is an established method of determining vertical facial balance. While this beauty concept is well acknowledged, putting it into practical use is difficult. Few facial structures can be easily changed vertically unlike increases in projection (horizontal) or transverse width.
The only facial structure that can easily be changed in the vertical dimension is the lower third of the face, that of the mandible. Such vertical mandibular lengthening is most commonly done through orthognathic surgery by mandibular advancement, either alone or in conjunction with maxillary downgrafting. But onlay augmentation can also be done along the inferior border of the mandible. (jawline It is not commonly done or thought of as there are no stock implants available that make it easy to do.
Case: This is a 21 year-old female who was concerned about her jawline, specifically that it was not long enough. She wanted a longer and more pronounced jawline. Her face was overall wide in all thirds including the jaw angles. She had wide-set eyes (type 1 hypertelorism) that were quite prominent with a lot of scleral show. But her lower face was vertically short with a small mouth horizontally. She had adequate horizontal chin projection but was short between the lips and the pogonion chin point.
A decision was between working with existing stock mandibular/chin implants or having a custom mandibular inferior border implant. Due to cost considerations ( doubling the cost of surgery), it was elected to proceed with off-the-shelf implants. One of the problems with this approach is that there is not a true mandibular border (jawline) implant. However, the geniomandibular implant composed of Medpor closely parallels this concept as it does lengthen the inferior border of the mandible (by 4mms) back to the mid-body of the mandible in most patients. By placing a spacer between the inferior border groove of the implant and allowing it to go back further and provide a taper, a modified jawline implant can be made out of a stock implant. This approach works if the implant is not needed to extend all the way back to the mandibular angle. Such a design is probably better for a female than a male who may need angle lowering as well. When combined with a mandibular angle implant, total jawline elongation can be obtained.
During surgery, a 3mm strip of Gore-Tex was added along the inside of the implant to get additional vertical length as well as extend how far back the implant would go. Through a submental incision, the implant was inserted and secured at the chin area with titanium screws. This implant can be placed without any risk of injury to the mental nerve as dissection is done below the exit of the nerve from the bone.
When seen at one week after surgery, the submengtal tapes were removed. She had minimal bruising and remarkably less swelling than one would anticipate. She has no restrictions on eating or jaw movement after surgery. While there was pain, it was less than what she thought would be. The implant can be seen to add to her vertical facial height without being excessively long.
Case Highlights:
1) Facial balance is a three-dimensional concept. The vertical dimension of the face, unlike horizontal projection and transverse width, is the least able to be changed and the most difficult historically.
2) Vertical elongation of the face for aesthetic balance can only be practically be done by changing the length of the mandible.
3) Aesthetic elongation of the mandible is done by onlay implant augmentation along the inferior border. This can be done using modified stock implants or having a custom implant made off of mandible model fabricated from a patient’s 3-D CT scan.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis Indiana
Background: A variety of mandibular (jaw) implants to improve the shape of the lower third of the face exist. They work very well for horizontal chin augmentation or lateral jaw angle enhancement. When the two are put together, a great improvement in the jaw line and shape can be achieved. But standard implants do not exist for treating an uncommon deficiency of the jaw, that of vertical deficiency. Lengthening of the lower face heretofore could not be done with implant techniques.
Case Study: A 55 year-old male wanted improvement in his ‘weak jawline and chin.’ It could be seen in profile that his chin was not that horizontally short. The lower third of his face was vertically short from front to back. This was the result of a mandibular deficiency which was detected in his bite, he had a complete 100% overbite. (lower jaw sits completely inside his upper) His mandible was overclosing thus giving him a vertically short lower jaw. While orthognathic surgery and orthodontics are the standard approach for this problem, he was understandably reluctant for that treatment at his age and state of his teeth. No standard jaw implant exists for this problem.
Using a 3-D CT scan of his mandible, a wrap around vertical lengthening jaw implant was designed in acrylic. The implant dimensions were based on facial measurements and his aesthetic desires. The acrylic mock-up was then sent to the manufacturer to be formally made and sterilized in silastic. (silicone rubber) This process took three weeks to complete.
The implant was then inserted onto the lower border of his jaw through a submental incision under the chin. There was no need for any dissection done inside the mouth. The soft tissues were elevated off of the bone around the chin and back to the jaw angle. The implant was then slide into place and secured to the bone with titanium screws. This procedure took one hour to complete under general anesthesia.
The increase in lower facial height and chin prominence was immediate. He reported some soreness but very little actual pain. It took about three weeks for all of the swelling to subside. He was ecstatic about the result and the change in his facial appearance was very positive. While this approach cost twice as much as a standard chin or jaw angle implant surgery, they were inadequate for what his face really needed to be in better proportionate balance. (vertical augmentation)
Case Highlights:
1) There is no standard off-the-shelf implant for vertical shortness of the chin or lower jaw.
2) Custom facial implants can be fabricated off of 3-D CT scans to fit specific bone deficiency needs. A wraparound mandibular implant is one such example of a successful custom facial implant.
3) Vertical lengthening of the jaw line and chin can have a powerful influence on increasing the strength and masculinity of the lower face in men.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis, Indiana
There is no doubting the influence that a strong jawline has on the appearance of the male face. From a well-defined chin back to the jaw angle, a straight and strong jawline creates a favorable lower third of the face which is aesthetically important in men. But creating a good jawline for those who don’t have one is not as simple as it may seem.
What makes up the jawline? It is a single bone of the mandible (lower jaw) that incorporates three distinct aesthetic regions. These include the chin, the body, and the jaw angles. The combination of all three ideally create a well-defined line (at the lower border of the jaw) that runs smoothly from the chin back to the jaw angle. It is broken up into three areas based on how it must be surgically approached. The use of chin implants for the front and jaw angle implants for the back are well known. But it is the central zone, the body, that poses the most challenging area to aesthetically augment.
If the body area is augmented with an implant, this poses three potential problems. First, there is no standard implant that is available or pre-fabricated for this application. As a result, one has to custom carve during surgery the shape and length of implant needed. Secondly, placing a body implant in between a chin or jaw angle implant creates a three-piece jawline implant that has the real potential of being able to feel the transition zones between them. This is particularly true at the back end of a chin implant and the front end of the body implant. Lastly, the purpose of most jaw body implants is to provide more projection to the edge or bottom side of the jawline. This makes placing it and holding it in place after surgery a potential challenge.
For these reasons, I feel that a custom fabricated one-piece jawline implant is almost always best. This requires preoperative modeling and an implant design which certainly adds to the cost of the operation. But if one is looking for a more vertical elongation to the entire jawline, this is definitely the way to go. One-piece implants, regardless of size, are always easier to place and will have less potential for postoperative problems.
When lateral jawline augmentation is desired, then the three-piece approach is more reasonable. The body and jaw angle implants can be placed inside the mouth while the chin implant is placed through an incision underneath the chin. Screw fixation is used for all implants as this is best way to prevent shifting or migration of the implant.
Every jawline patient must be looked at individually and a specific implant approach used for each depending upon their goals and aesthetic desires. The concept of jawline augmentation with multiple plastic surgery options intermingles a variety of factors that defies one standard approach.
For the older male, creating a stronger jawline must take into account the development of jowling from aging and gravity. A facelift (neck-jowl lift) would be a necessary part of the plan. The use of one or two implants, at the chin and jaw angle, may be all that is needed to recreate a more well-defined jawline prominence.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
One of the most dominant and defining features of the male face is the jawline. While the chin is a part of the jawline, it does not represent the entire dimension of the lower third of the face. It represents only the central third. The dimensions of the jawline follow the curvature of the mandible from one angle to the other. In assessing the desire to improve the lower male face, one has to consider the entire jawline.
Chin implants have really evolved since their introduction decades and the changes in implant design and styles can really be beneficial in male chin augmentation. The most important change has been that they have been extended in their shape rather than just a central ‘button’. In men, these keeps the chin from getting too narrow from the frontal view. These extended anatomicn implants are longer and more tapered at the ends, although they can still be placed through a very small incision right under the chin. Because they extend back further they give an enhanced but still natural appearance to the chin. This is achieved by filling in the jawline between the chin and the back of the jaw, slightly widening the anterior jawline making the overall look more balanced. There is even a square chin style that can make the chin quite square if one desires a strong change.
The sides and back part of the jawline can be enhanced through the use of jaw angle implants. Placed over the junction of the posterior and inferior mandibular borders, the implant’s design and shape can help make the jaw angle’s definition more pronounced. By so doing, particularly when done on both sides, the width of the back of the jawline is increased creating a stronger and more masculine facial appearance.
Total jawline enhancement or augmentation requires a three implant approach, a chin and two jaw angles. The combination of all three can make quite a difference in improving the look of the lower third of the face. The most anterior edge of the jaw angle implant, hwoever, is not long enough to ever reach the back end of a chin implant. So there will always be a gap between the two. I do not think that this is ever much of a problem for most patients as adding width to the middle of the jawline is not that aesthetically significant. But a fourth (and fifth) piece can be added if desired which is best done with a hand-carved piece of Gore-tex block which is fit and screwed in between the two other implants. One will always be able to feel some step-offs and edges when there are this many implants however.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Facial asymmetry exists whenever one side of the face does not match the other in size and shape. The most common reason this occurs is due to different development patterns of the underlying facial bones and is most commonly seen in people who have some facial bone development issues such as cleft lip and palate and other craniofacial birth defects. Sometimes it may just be soft tissue only and the facial bones are fairly symmetric. But aside from these types of patients, some people merely have a light or mild facial asymmetry of which the cause is not obvious or will ever be known. In essence, it is just you.
In many cases of facial asymmetry the most common finding or cause is that the lower jaw is different between the two sides. Because the lower jaw is moveable (the only facial bone to do so) and has an L-shape in the back above which the jaw joint hinges, it is the one facial bone that is most prone to having differences between the two sides. Most commonly, these differences are back at the angle area and along the jawline that comes forward. This can create a very visible difference between the jawlines when looking straight forward. It is the most common type of facial asymmetry that I see. Sometimes I will see someone who has a crooked chin, where the chin point if offline, but the origin of the crooked chin usually comes from differential jaw growth between the two sides.
In cases of facial asymmetry it is initally important to make sure that the jaw asymmetry is not best corrected by actually moving the whole jaw and putting the teeth into a better bite relationship. If one is young and the jaw asymmetry is significant, how the teeth come together will determine if this is the best long-term solution. But assuming that jaw bone movement is not a good solution, the more common approach is to correct it with the placement of implants.
Jaw angle and jawline implants can be fairly simple methods of improving jaw asymmetry. These implants are almost always placed through inside the mouth. Off-the-shelf jaw angle implants exist but there is no off-the-shelf jawline implant. Jawline implants have to be fashioned at the time of surgery, usually out of a block or thick sheet of semi-soft material. (Gore-tex or SAM is what I prefer) The key to success with implant augmentation is to be certain of exactly where the jaw asymmetry is. Implants will do little good if they aren’t in the area of bone deficiency or asymmetry. Sometimes this is obvious by feel, other times it may be better to get a 3-D CT scan and have an exact skeletal image to work off of. In rare cases, I have even had a 3-D model made from the CT scan and custom-fabricated the shape of the implants prior to surgery. This is the most exacting method but also the most costly.
When having implants placed for any type of facial asymmetry it is important to walk into surgery with the understanding that the outcome will be better…but not perfect. Surgical facial augmentation with implants is as much an art as it is an exact science.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The use of facial implants for male face enhancement is common and the traditional areas include the chin, cheeks, and jaw angle areas. Every now and then, I get a request or see a patient who really enhancement in a different area of the jaw….the vertical dimension. Making the jawline longer in the vertical dimension to increase lower facial height and put the face in better overall balance. Most of these unusual cases exhibit an underlying jaw deficiency problem, often with a significant overbite relationship at their teeth, indicating a jaw that is both short in the front-back dimension (horizontal development) and in the up and down dimension. (vertical development at the ramus)
In correcting this type of jaw problem, the ideal solution for most of these patients is a course of orthodontics followed by traditional orthognathic surgery. While this may be ideal, most of these patients are beyond their teenage years and do not want to make the multi-year investment of time to make a formal anatomic correction based on the bone. A ’short-cut’ solution is to augment the deficient areas with a synthetic implant. While the actual procedure is not difficult to do, the problem is in finding a commercially-available implant that will match the patient’s problem. When it comes to vertical lengthening of the mandible from one side to the other (wrap-around), there is no such off-the-shelf implant option.
Sometimes a standard chin implant, combined with a jaw angle implant, that is positioned low on the bone below the native bone edge may suffice. But there will be a gap between where the chin implent ends and the jaw angle begins. In some cases, it may work but it is a piecemeal approach that is fraught with problems such shifting of the implants after surgery. (in this case , the jaw angle implant)
A better solution is to have a custom wrap-around implant made off of a computer-generated model. A 3-D CT scan can be done from which an exact replica of the jaw (mandible) can be created. Then a mock-up of the implant (by me) can be done in acrylic to create a one-piece wrap-around jaw implant that sits on the inferior border of the jaw, lengthening it throughout. The acrylic mock-up is then sent to a manufacturer where they make a formal silicone rubber implant. While a lot of work is done on the front end, the implant is easily placed through a small incision under the chin. (it is flexible so it easily folds on itself to be easily inserted through a small incision) It is fixed with a single screw underneath the chin so it does not ever move. It really is nothing more than a long extended chin implant that runs from one jaw angle to the other, but is on the bottom edge of the bone.
I have done this procedure several times over the years and found it to be quite successful. There is some significant cost upfront fron the CT scan, jaw model, and final implant (around $5,000, surgery costs are additional) but it is the best way to go when one is looking for this type of jaw implant)
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis