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Archive for the ‘jawline reshaping’ Category

Technical Strategies – Intraoperative Positioning Guides for Custom Jawline Implants

Sunday, February 18th, 2018

 

Custom jawline implants offer an unparalleled ability to reshape the entire jawline and the lower face. Combining chin and jaw angle augmentation in a connected fashion can have a powerful effect given the surface area of the lower jaw that it covers. Because of this surface area coverage even small amounts of implant thickness create an external shape change that is more than I would think.

While the appeal of such a lower jaw implant is obvious, it is not a perfect technology. The design process remains subjective since the software can not yet tell us how to design the implant to achieve any patient’s specific desired look. The surgeon must provide that information to the best of his/her ability and hope the implant’s shape and various thicknesses throughout achieve what the patient wants.

In addition to design considerations, just because an implant is custom designed for the face does not mean that its surgical positioning will match exactly how it was designed to fit on the bone. While this is one of the obvious surgical goals, there is always the chance of implant malposition. Custom facial implants are not like Lego blocks, they do not snap fit together. (I wish they did as it would make the surgery a lot easier) The surgeon still has to place a smooth slippery implant on a smooth bone surface under indirect vision.Through small incisions and pockets that are not fully visualized, the surgeon must position the implant. This is a lot harder to do than how the implant design appears on the 3D skeletal model.

In some patients who have had prior osteotomies (sagittal split ramus osteotomy and sliding genioplasty), the indwelling hardware is actually very helpful. The implant can be designed around or over the hardware which serves as an intraoperative guide for its surgical placement as this hardware is always seen through the incisions.

But most patients don’t have these handy intraoperative guides. As a result it is very helpful to incorporate some intraoperative positioning guides on the implant’s design. I do this by making an extended tab of material that goes up to the ascending ramus opposite the 2nd/3rd molar teeth. Since this can easily be seen through the posterior vestibular incision, it provides a guide as to how the posterior and inferior aspects of the angle portion of the implant is positioned in the bone. (since this part of the implant can not be seen)

Once the custom jawline implant is positioned and secured his tab of material can be removed. It is always best to have any implant material as far removed from being directly under the incision as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Square Custom Jawline Implant Design Principles

Tuesday, February 6th, 2018

 

The well defined jawline has become a desirable facial feature. Actually I do not think that a weaker or poorly defined jawline has ever been a desired facial trait. But with today’s aesthetic facial trends highlighted by strong social media exposure has brought this desirous lower facial shape into high focus. While most commonly pursued by men, it is not uncommonly requested by some women as well.

For many patients the only way to really change the shape of their jawline in a reliable manner is with a custom made jawline implant. With a wrap around shape and the ability to set its angles and dimensional thickness, it is no surprise that it can be very effective. In the right face, that is not overly round or has very thick tissues, a more angular or squared jawline shape can be obtained.

But the key in any jawline implant design is what should that shape be? While every person is different and there is no set shape that will work for everyone, there are some basic guidelines I have learned from doing hundreds of these implant designs. (and then seeing their actual effects after being implanted)

For a square jawline implant the first step is to set the angles. From the frontal view the chin should be squared off at the vertical line of the canines. The jaw angles should be squared off at the desired width as well as at the horizontal level of how one wants t set the new jaw angle projection position. (width only, primarily vertical or some combination thereof) This is the hardest angle point to set but one of the most important.

In the side view the jaw angle shape is determined. Here it is important to not make it too square. But doing so it runs the risks of having the back part of the angle end up behind where the masseter muscle can cover it. So it must not be 90 degrees but more open at 110 degrees of so.

The width of the jaw angle should not exceed a vertical line dropped down from the widest part of the zygomatic arch. As you don’t want the width of the lower face to exceed the midface. (unless that is the patient’s desired aesthetic goal)

With this as a general guideline for the jawline implant shape its dimensions (thicknesses) must be determined. For this there are no exact guidelines but the setting of the chin and jaw angle shapes and positions will serve as a good guide.

Despite the fact that wrap around jawline implants are custom designed, it is not an exact science nor is there any guarantee that the patient’s desired result will be obtained. But by following certain design guidelines the chance for a satisfactory jawline augmentation change is more likely.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Implant Replacement for Displaced Chin and Jaw Angle Implants

Saturday, February 3rd, 2018

 

Background: A stronger and more defined jawline is a frequent aesthetic facial request for both men and women today. While jawline augmentation used to exclusively refer to the chin (front part of the jaw), today a more comprehensive approach is usually done for an entire lower facial effect from the chin back to the jaw angles.

Augmentation of the jawline can be successfully done by a variety of standard preformed chin and jaw angle implants. With almost ten chin implant and three jaw angle implant styles, there are a large number of possible implant combinations to satisfy most patient’s aesthetic needs. While putting together these various implants for each patient needs is an art form that requires an understanding of their external facial effects, their surgical placement is more straightforward with much less variability.

But what makes jawline augmentation unique is that it requires three implants to achieve a total lower facial effect. As every single implant has its own inherent risks (infection, malposition and undesired aesthetic effect) this makes such risks three times greater for a total jawline augmentation. Such risks are commonly recognized  for any other paired or bilateral implants (e.g., cheeks, temples) but no other place on the face (or body) has a three-fold implant complication risk.

Case Study: This male desired a more defined jawline with a square chin and stronger jaw angles. He had undergone a three implant jawline augmentation with standard chin and jaw angle implants. While he was happy with the chin and right jaw angle implant result, his left jaw angle was asymmetric. A 3D CT scan sows that the asymmetry was caused by malpositon of the left jaw angle implant.

He decided to have a one-piece total jawline implant made based on the dimensions of his existing implants rather than just reposition the left jaw angle implant. This also gave him the opportunity to add a little more width to the chin and some width to the sides of the jawline to the connections between the chin and jaw angles.

Under general anesthesia his existing chin and jaw angle implants were removed through existing submental skin and intraoral vestibular incisions. Through the same incisions the custom jawline implant was inserted and fixed into position.

A custom jawline implant, besides allowing for chosen dimensions before surgery, lessons the risk of malposition that does naturally exists the using three separated and not connected implants along the jawline.

Highlights:

1) A three piece total jawline implant approach has three times the chance of implant malpositions.

2) A custom jawline implant because it is one single implant has a much lower chance of a malposition problem.

3) Having existing standard implants is an enormous aid in designing a custom jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Implant Replacement for Malpositioned Chin and Jaw Angle Implants

Sunday, January 7th, 2018

 

Background: Jawline augmentation today usually refers to enhancement of its three primary aesthetic points, the chin and two jaw angles. There are a variety of standard preformed chin and jaw angle implants to achieve this effect and, with proper implant style and size, satisfactory results can be achieved.

But beyond the challenge of selecting the right implant style and size for three different bony jaw areas, there is the need to place them in the proper bony location to exert their desired external effects. The latter is often taken for granted by the patient but not by the surgeon. Placing three implants at different locations on the jawline without being able to reference one to the other due to the limitations of incisional access makes this part of the operation more difficult than it seems. This is far more challenging than placing a single chin implant or even paired cheek implants.

As a result the incidence of implant malposition and asymmetry is not all that uncommon in a three implant approach to jawline augmentation. This risk is magnified when the patient has pre-existing jaw angle bony asymmtetry which may or may not have been recognized before surgery.

Case Study: This middle-aged male had total jaw augmentation previously with a standard anatomic chin and widening jaw angle implants. While the patient recognized that his jaw was asymmetric after the surgery, his surgeon assured him the implants were in good position. A 3 D CT scan showed that the chin implant was positioned too high and to the left and the jaw angle implants were in completely different positions, neither of which was in ideal position.

Using this 3D CT scan a one-piece jawline implant was designed to correct his asymmetries. The dimensions of his existing implants (projections) served as a good guideline as to the size of the various ‘corners’ of the jawline implant.

Under general anesthesia and using an external submental skin incision combined with bilateral posterior vestibular incisions, his chin and jaw angle implants were removed. The new one-piece jawline implant was able to be inserted as the intact piece by which it was designed. His results with pictures taken years later showed good jawline/lower facial asymmetry and better chin and jaw angle projections.

There are many patients in whom standard chin and jaw angle implants work well. But it is not easy to successfully place three independent jaw implants in a perfectly symmetric fashion. Even with a lot of surgical experience it can still happen. When a three-piece jaw implant approach has not been successful, a custom jawline implant will offer improved results by its ‘one implant’ design.

Highlights:

1) Total jawline augmentation done with standard implants has a relaltively high risk of malposition/asymmetry of at least one of the implants since there are three implants used.

2)  A 3D CT scan can confirm standard jawline implant positions as well as be used for a one-piece total jawline implant.

3) Indwelling implants provide dimensional guidelines in designing a custom jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Remove and Replace Custom Jawline Implant

Sunday, December 17th, 2017

 

Background: The jawline for men and women is the key feature of the lower face. While once all focus was on the chin, this perspective is short-sighted today. While many patients will still benefit by chin augmentation alone, a growing number of patients want/need a total jawline approach to achieve their aesthetic facial goals.

Total jawline augmentation consist of changing the chin and the paired jaw angles, the three points of the jaw. There are numerous standard preformed chin and jaw angle implants that are available to do so and the ‘three corner’ jawline technique will work for many patients. But for those patients seeking a linear jawline effect that connects the three corners or who have dimensional needs that may exceed what standard implants can do, a custom jawline implant is the  other option for total jawline augmentation.

Designed and made from the patient’s 3D CT scan a one-piece implant is created from jaw angle to jaw angle. It has the advantage that as a connected piece it is less prone to implant positioning asymmetries than that of three implants. But like all other facial implants, jaw implants included, what the dimensions should be to achieve the patient’s goals is not an exact science.

Case Study: This young male had a prior history of a custom jawline implant. While providing improvement it was not dimensionally adequate and there was jaw angle implant asymmetry. A new 3D CT scan was used to determine the implant’s position and shape.

Having any jaw implants, custom or standard, is an enormous help in knowing how to design a custom jawline implant. Knowing the inadequacies of one implant design provides insight into how to make the next one better. From that information a new custom implant designed. Increased chin projection and vertical lengthening of the jaw angles were additional desk features.

Under general anesthesia and through a three incisional approach, the existing implant was removed and replaced with the newly designed implant. The improvements in the jawline shape were consistent with the implant design improvements.

The effects of a custom jawline implant are based on how it is designed and its position on the bone. Unfortunately there is no exact method to determine before surgery what external facial effect any implant design will create. When the first implant design ‘fails’ it still provides useful information as to how to make the next implant better.

Highlights:

1) A custom jawline implant has the best chance to create a more angular and well-defined jawline….provided the dimensions are correct.

2) Most custom jawline implant designs have to be ‘over exaggerated’ as their effect is blunted by the overling soft tissue cover.

3)  A second custom jawline implant can be done to replace a first one if the dimensions are not adequate.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Surgery for Mandibular Cherubism

Sunday, November 12th, 2017

 

Background: Cherubism is a very rare genetic disorder that primarily affects the shape of the lower jaw bone. The painless ‘swelling’ of the lower jaw creates a fullness that appears like an extreme form of mumps and. as a s result, the chubby facial appearance is equated to that of cherubs as often seen in paintings of biblical times and the heavens.

The facial chubbiness comes from the overgrowth of the jaw. The patient’s face becomes enlarged and disproportionate due to the fibrous tissue and atypical bone formation. It creates expansile growth of the ramus of the mandible primarily. It expands out both sides of the cortical covering of the ramus and replaces it with fibrous tissue and cyst-like formations. The reason that this extensive fibro-osseous growth occurs is not known but an imbalance between the normal osteoclastic and osteoblastic remodeling of the bone with growth is altered. It has been linked to a genetic mutation of the SH3BP2 gene on chromosome 4p16.3.

It is an autosomal dominant disorder which occurs primarily in males. It usually appears in childhood at around age 5 or 6. It will continue to grow until puberty when many affected patients stabilize and the abnormal bone growth ceases. In more mild cases the expanded bone may return to a normal bone shape and facial appearance. But in more moderate and severe cases this does not occur. In more severe cases the jaw growth goes unchecked and continues to deform the face.

The only treatment for cherubim is surgical excision of the affected bone. The cortical bone separates easily and exposes the now fibrous and cystic diploid space. Care must be taken in removing this soft soupy fibrous tissue to not injure unerupted teeth and the inferior alveolar nerve.

Case Study: This 7 year-old male child presented with a slowly progressive chubby face. His mother knew exactly the cause since there was a family history of cherubim. She herself was affected in a more moderate fashion which regresses to normal during her teenage years. A 3D CT scan showed the classic expansion of the cortices of the rams of the lower jaw with soft tissue formation between the two sides. The cortical expansion was fairly equal on both sides. The mother wanted him treated because of his appearance and feared it would get much worse.

Under general anesthesia an intraoral approach was used through a vestibular incision to access the enlarged outer ramps of the mandible. The outer cortex of bone was removed with a reciprocating saw to expose the soft gelatinous content inside. Curettes were used to scrape out the softer tissue, being careful to not injure the nerve which was exposed. All bony edges were then smoothed down and Tisseal adhesive was used for hemostatic over which the mucosa was closed with reservable sutures.

Cherubism is rarely seen let alone surgically treated. Surgery to do a subtotal resection  of the excessive fibro-osseous tissue is a low risk procedure that may either prevent further disease progression or hasten an earlier resolution of it.

Highlights:

1) Cherubism is a very rare cranofacial disorder that primarily affects the lower jaw.

2) Surgical treatment may be indicated when the degree of facial disfigurement is  source of emotional distress and is progressive.

3) Intraoral subtotal resection of cherubism is the preferred technique to avoid external facial scarring.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Jawline Augmentation using a Three Implant Technique

Wednesday, October 25th, 2017

 

Background: The shape of the lower face is primarily influenced by the size and dimensions of the mandible or lower jaw. Being the only moveable bone on the face it has a unique shape due to the biomechanical stresses placed on it as well as having to contain up to sixteen teeth that pass loading forces onto the upper jaw. It has three prominences that make up its identifiable tripartite structure, the anterior chin and the posterior jaw angles. While the chin is the mandible’s most recognized aesthetic feature, the jaw angles are really like the paired set of chins on the back part of the jaw.

While chin augmentation has been around for over five decades, jaw angle augmentation is much more recent. Unlike the chin, augmentation of the jaw angles can only be done by implants and doing so is far more complicated than that of the chin. Besides the anatomic fact there are two jaw angles, their location underneath the strong masseter muscles creates considerations of incision location, implant shape and size and its location on the bone and how it may affect muscular position and shape.

While the ideal method for total jawline augmentation is that of a custom made wrap around jawline implant, many patient’s may not need that technology or prefer not to undergo its use. Standard chin and jaw angle implants can work well for many patients and their wide variety of sizes and shapes create a lot of aesthetic jawline augmentation options. But how to mix and match these implant sizes and the challenges of placing three separate implants in their proper bony positions makes getting symmetric and aesthetically satisfying results challenging.

Case Study: This young male wanted a total jawline augmentation with a result that was of a modest enhancing effect. He didn’t want it too strong or to look overdone. His natural jaw was not weak or overtly deficient but had softer highlights of the chin and jaw angles.

Under general anesthesia, a small square chin implant was placed through a submental incision. Through posterior vestibular intraoral incisions, medium square widening jaw angle implants were placed and secured by titanium micro screws.

His after surgery results showed a more defined jawline that had better chin and jaw angle angularity. The implants had acceptable symmetry and were not oversized.

While this patient had a good result using standard chin and jaw angle implants, the risks of revisional surgery with three independent bone areas of augmentation is not low. Between the size and shape of the implants and their proper and symmetric placement on the bone, the average risk of an aesthetic revision for the dozens of influencing and interconnected possible variables is 50% or higher.

Highlights:

  1. Complete jawline augmentation consists of highlighting the three corners of the jaw, the chin and bilateral jaw angles.
  2. A wide variety of standard chin and jaw angle implants exist to satisfy many patient’s aesthetic jawline needs.
  3. With three independent implants along the jawline it is important that patient’s appreciate the relatively high rate of aesthetic revisions that can occur.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Submental Technique for Bony Chin and Jawline Asymmetry Correction

Wednesday, October 25th, 2017

 

Background: Lower facial asymmetry is most commonly associated with the shape of the jawline. While patients often present with chin asymmetry, closer inspection often reveals that it extends back along the jawline as well. With the chin asymmetry the jawline on the longer chin side is lower and conversely it is higher on the shorter chin side. A debate can be had about which is the normal side and whether the condition is hypoplasia or hyperplasia which has great relevance when it comes to treatment planning.

True lower facial bony asymmetry has soft tissue asymmetries as well which would be consistent with that of a developmental origin. The lips will be tilted with different horizontal positions of the mouth corners. The base of the nostrils will be tilted and even the eyes may have subtle differences in the horizontal lines between the inner and outer canthi. Most of these soft tissue asymmetries are far less correctable than that of the underlying bone

Correction of chin and jawline asymmetry must take into consideration numerous anatomic factors. In the chin area the short length of the tooth roots do not pose any restrictions for the amount of bone that can be removed. But in the jawline behind the chin the location of the inferior nerve as it courses through the bone is, however, a potential surgical restriction. When vertical bone reduction is indicated (facial hyperplasia) preoperative x-rays are needed to determine the limits of these bony changes.

Case Study: This young female presented with chin asymmetry with a longer right side and a visible tilt of the chin to the left. Physical and radiographic examinations  showed that a right facial hyperplasia was the cause with vertical elongation of the entire jawline which drove the position of the chin to the opposite side. This was evident at facial rest but more apparent when smiling. A panorex x-rays showed the amount of bony differences between the two sides with the jaw angles and intrabony nerves highlighted.

Under general anesthesia a submental approach to the chin and right jawline resha[ing was used. Initially the chin asymmetry was addressed by an inferior border shave across the bone, horizontal deprojection and a left corner angled reduction. The right jawline ws reduced by an inferior border shave of 7mms back to the anterior attachment of the master muscle. Redundant soft tissue was removed over the chin area and the muscles reattached along the chin with sutures suspended to bone holes.

The immediate intraoperative view of the chin showed he improved symmetry as well as an overall rounding effect to ‘desquare’ the chin as well. The cant of the smile line and occlusion above the chin will remain the same as before surgery as would be expected.

The aesthetic management of the chin and jawline asymmetry from hyperplasia that does not include occlusal adjustments is based on removing bone along the inferior and/or inferolateral border. The submental approach offers a direct line of sight method doing so with the greatest accuracy and safety to the inferior alveolar nerve. The fine line scar under the chin is a reasonable aesthetic tradeoff for these more predictable any changes. Radiographic surgical planning is essential and, while 3D CT scans have the most visual appeal, a traditional panorex x-ray offers a vert measurable method to determine a safe amount of vertical bony reduction along the inferior borders.

Highlights:

  1. 1) Chin asymmetry is often associated with jaw asymmetry as well.
  2. 2) The submittal approach offers the most effective reshaping of the chin and jawline due to line of sight visual access.
  3. 3) The location of the metal nerve and tooth roots can limited the extent of bony symmetry that is possible to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Female Jawline Augmentation in the Aging Face

Monday, August 28th, 2017

 

Jawline augmentation has traditionally been thought of as male procedure. Envisioning a defined and strong jawline is a well known facial feature that has historically implied masculinity and a strong personality. But in today’s world a good jawline is no longer gender specific. Many women of all ages (although more so in younger than older women) now seek jawline enhancement. Undoubtably driven by jawline shapes of well known celebrities and models, and the strong influence of social media as well, female jawline augmentation is an emerging aesthetic facial surgery procedure.

Regardless of whether it is a male or female, one benefit not often appreciated about a stronger jawline is the structural support that it provides to the soft tissues of the lower face at any age. This can be seen in jaw angle reduction surgery where some patients complain of the soft tissue sagging that occurs when the jaw angles are removed. Restoring or augmenting the jawline shape lifts up loose or sagging tissues which are obtained from the neck rather than that of the face. (in other words tissues are pulled up not down in jawline augmentation)

While jawline augmentation provides definition to the younger jawline, an often overlooked benefit is what it can do in the older jawline. With the descent of facial tissues over the jawline with aging (jowling), a jawline implant can help smooth out these soft tissue redundancies. Depending upon the amount of jawline and neck sag, a jawline implant can be done alone or in conjunction with some form a lower facelift.

In the thin older female with jowling and a mildly weaker jawline, a thin jawline implant can be very effective. It does not provide any jaw angle width augmentation as it stops short of the jaw angle region. It provides chin and jawline definition and in many ways is a jawline extender. Such a long but thin implant can be inserted through a submental incision or even intraorally.

In the female facelift patient such an implant should be considered. While once managed by a chin-prejowl implant placed at the same time, a more contemporary approach employs this more complete jawline augmentation approach.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Custom V-Line Jaw Implants

Sunday, July 23rd, 2017

 

Background: The shape of the jawline has taken on great aesthetic importance in contemporary society. This is not just for men but for females as well. But the desired shape of the female jawline is different from that of men. It is desirous to be more tapered from back to front and have more of a triangular or V-shape. While some women have this jaw shape naturally, most do not.

The well known V-line jaw surgery comes from Asia where it is commonly done. The Asian face often has a bigger lower jaw with larger jaw angles as part of an overall wider and flatter facial shape. Dramatic reductions in the jawline through amputation of the jaw angles and jawline combined with a T-shaped chin reduction creates the V-line effect.

But in many Caucasian faces such reductions of the jaw will not produce the same reshaping effect or can not be done with a smaller jaw size. The opposite approach, augmentation of the jawline, may be needed to create a V-line effect.

Case Study: This 26 year-old female wanted to have a more tapered jawline look. She had a prior chin implant placed but it did not create the desired effect. Her 3D CT scan showed a chin implant sitting high on the chin bone  way above the edge of the chin bone. She also had high jaw angles.

Her 3D CT scan was used to make vertical lengthening jaw angle implants (with minimal width) and a v-shaped chin implant that created a completely central augmentation.

Under general anesthesia, her chin implant was initially removed and replaced through a submental incisional approach. This was to ensure that the implants sat down on the bone as low as it was designed and to place screw fixation. The jaw angle implants were placed through an intraoral approach using posterior vestibular mucosal incisions. Because it was a vertical lengthening implant, where half of the implant sits off the bone, double screw fixation was used.

A more tapered and shaped jawline is not always obtained by bone reduction. In some non-Asian jaws augmentation of the jaw angle and chin points may suffice.

Highlights:

  1. V-line jaw reshaping is classically done by chin and jaw angle bine reduction/reshaping.
  2. In the Caucasian face augmentation of the chin and jaw angles may be needed to create the V-line effect.
  3. Custom chin and jaw angle implants can be designed to create a more tapered jawline shape.

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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