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Archive for the ‘jawline reshaping’ Category

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

Case Study – Custom Female Jawline Implant

Sunday, July 9th, 2017

 

Background: The shape of the lower face is defined primarily by the size and dimensions of the lower jaw. While a strong or more defined lower jaw shape has always been desired by men, it has also taken on more significance in women with contemporary aesthetic facial standards. The well defined female jaw shape can be seen today in models, actresses and many other celebrities.

The difference between a distinct male and female jawline is really a function of size in most cases. They share similarities of a linear smooth shape from angle to angle and a visible jaw angle shape. The female chin is less square and more tapered and the jaw angle has less lateral flare. But a visible uninterrupted jawline is the hallmark of a defined lower face in a female. It doesn’t have to be big but it has to be defined.

Case Study: This 35 year-old female wanted a better defined lower jawline. She had been receiving injectable fillers for a chin augmentation effect. but wanted a permanent result that improved the entire jawline. From a 3D CT scan of her a custom jawline implant was designed providing 7mms of horizontal chin projection with 3mms of vertical length and 7mms of jaw angle width with 5mms of vertical length.

Under general anesthesia the jawline implant was placed through three intraoral incisions. (one anterior and two posterior) The front and back jawline pockets were connected by a subperiosteal tunnel under the mental nerves exits on each side.

Her six months after surgery results showed an improved jawline shape that had better jaw angle definition and a linear jawline shape that came together into a tapered chin. One of the key features to her improved jawline shape was the increase on overall vertical length.

Most female jawline implants would be considered more modest in size in comparison to many men. This is, of course, due at least to a body size difference. But it is also relevant to overall implant size compared to that of the jaw size.

Highlights:

  1. Total jawline augmentation, from angle to angle, requires a custom jawline implant.
  2. A linear shape to the jawline requires a single piece implant.
  3. Female jawline augmentation is more about shape and definition than it is about size of the implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Defining Implant

Sunday, June 4th, 2017

Background: Augmenting the jawline today is more than just a chin or jaw angle implants. To change the entire jawline from angle to angle in a smooth united fashion, custom jawline implants offer aesthetic results not previously obtainable. Made from the patient’s 3D CT scan they provide a precise fit to the bone as well as smooth transitions into the surrounding bone.

Designing a custom jawline implant allows for any type of dimensions/thicknesses/shape provided that the soft tissue will permit it. What those implant dimensions should be for any specific patient depends on their goals. However, how to translate these aesthetic goals into dimensional numbers is not an exact science. The computer design process can only create what it is told, it does not know how to make anyone look exactly like they want. Such custom facial implants designs remain an art form based on the surgeon’s input at the present time.

Some patients prefer a more subtle or modest change to their jawlines. They want to provide some accents to their jawline not necessarily make it ‘big’ or have any extreme change. Creating more visible jaw angles and chin points and a smooth connection between them is their facial goal.

Case Study: This 35 year-old male wanted a jawline enhancement to create an overall more distinct jawline. He didn’t want it too big or too  noticeable. Using a 3D CT scan a custom wraparound jawline implant was designed with most changes at the chin (2mm forward and 3mms vertical elongation) and the jaw angles. (4mms vertical elongation and 4mms jaw angle width)

Under general anesthesia and through two intraoral incisions and one submental incision, the custom implant was inserted in a subperiosteal plane as a one-piece unit. It was secured with three small screws at the chin and jaw angles.

He had a full recovery at six weeks after surgery. When seen three years later he had a subtle but distinct change to his jawline as would have been expected given the modest size of the implant’s dimensions. A smooth connection existed between the front and back end of the jaw creating a smooth linear jawline effect.

Highlights:

  1. A custom jawline implant augments the entire jawline from angle to angle, hence the term ‘wraparound’ to describe it.
  2. Selecting the dimensions of the implant during its preoperative design is an art form for which there is not exact science.
  3. The implant’s dimensions can be modest to only create a jawline enhancing effect.

Dr. Barry Eppley

Indianapolis, Indiana

Female Jawline Enhancement

Thursday, March 9th, 2017

 

The presence of a discernible chin has always been an important aesthetic feature of the lower face in both men and women. While the desired amount of projection will vary between the genders, it is clear that having some chin projection is better than having little or none.

While the chin has always been perceived as an important facial feature, the perception of the entire jawline has taken on greater aesthetic significance today. This means the shape and projection of the back part of the jaw, known as the mandibular ramus or jaw angle, also gives the lower face a fuller and more pleasing appearance. Just like the chin that projects the front part of the lower face, the jaw angles project the back part of the lower face.

Angelina Jolie Square Jaw Angle Dr Barry Eppley IndianapolisWhile stronger jaw angles have been historically associated with men, it also equally applies to women today as well. This can be seen in many well known female celebrities such as Angela Jolie, Olivia Wilde and Hiliary Swank, to name just a few. They all have a  distinct and well defined jawline because they have a vertically long and almost squared shaped jaw angle. It does not necessarily have to be very wide but it is its vertical length and defined posterior and inferior ramus outlines of the bone that give a ‘cut look’ to the jawline. In essence it makes the jaw stand out distinctly from the neck below it.

mandibular plane angleA strong and defined jaw angle is associated with a low mandibular plane angle. The mandibular plane angle is a measurement introduced in orthodontics many decades ago to assess the steepness of the jaw in relation to the base of the skull. (normal is around 30 degrees) It is the anterior angle formed by the intersection of the Frankfort horizontal plane and a tangent to the lower border of the jawline. (in orthodontics it is the angle formed by the intersection of SN and GoGn) The Frankfort-mandibular plane angle is affected by the vertical development and length of the mandibular ramus.

Vertical Lengthening Jaw Angle Implant data-lazy-sizes Dr Barry Eppley IndianapolisFemale Square Jaw Angle Implants result oblique view Dr Barry Eppley IndianapolisFemale Jaw Angle Implants result right side view Dr Barry Eppley IndianapolisThe high and indistinct jaw angle can be treated by a vertical lengthening jaw angle implant. This is a special jaw angle implant that drops down the jaw angle by the lengthening provided by the implant. Most women need the vertical jaw angle implant as opposed to the more traditional widening jaw angle implant. While the implant does not look very big, it is surprising how powerful an effect it can have on the shape of the lower face.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jawline Implant Replacement

Monday, January 23rd, 2017

 

Background: A more complete jawline augmentation is most commonly done using standard chin and jaw angle implants. With good implant selection and ideal placement on the jawbone, an enhanced and satisfying jawline can be achieved. While numerous options in both silicone and Medpor facial implants exist, the material used is of no biologic or long-term consequence. What matters is the shape and size of the implants used.

While more successful than not, a three implant jawline implant approach is associated with a higher rate of complications than any one single facial implant. With three implants the associated risks of infection, implant malposition and undesired aesthetic effects are…three times higher than that of a single implant. By far, implant malposition (asymmetry) of the jaw angles and undesired aesthetic results make up the vast majority of jawline implant complications and the need for revisional surgery.

When the aesthetic results of standard chin and jaw angle implants are inadequate the most effective approach is to make a new implant using a custom approach. This is particularly relevant if the standard implants were very inadequate for the patient’s desired aesthetic needs.

Before Custom Jawline Implant Dr Barry Eppley IndianapolisMedpor Chin and Jaw Angle Implant Jawline Augmentation Dr Barry Eppley IndianapolisCase Study: This 42 year-old male previously had Medpor chin and jaw angle implants to try and create a more masculine and well defined jawline. While he had no medical complications from his implants and they were placed fairly symmetrically, they did not come close to the desired jawline effect. A custom one-piece wrap around jawline implant was designed from a 3D CT scan and a stone jaw model as a replacement.

Medpor Jaw Implant Removals Dr Barry Eppley IndianapolisCustom Jawline Implant design on model Dr Batrry Eppley IndianapolisUnder general anesthesia, his Medpor chin and jaw angle implants were removed through his existing external submental and intraoral posterior incisions. The jaw angle implants were particularly difficult to remove due to tissue adherence and being wrapped around the bony jaw angles. The implants and their fixation screws were removed in many pieces.

Custom Jawline Implant Replacement of Medpor Implant result front view Dr Barry Eppley IndianapolisCustom Jawline Implant Replacement of Medpor Implants result oblique view Dr Barry Eppley IndianapolisCusytom Jawline Implant Replacement for Medpor Implants result side view Dr Barry Eppley IndianapolisHis new custom jawline implant was inserted and fit perfectly to the bone as designed on the 3D CT scan. His immediate surgery results showed a dramatically different aesthetic outcome from his standard implants with a much more defined jawline appearance.

Highlights:

1) Replacement of inadequate standard chin and jaw angle implants is best done with a custom jawline implant design.

2) Removing Medpor facial implants can be very challenging particularly over the jaw angle region.

3) Placement of a total custom wrap around jawline implant can be done through the same incisions as the original chin and jaw angle implants were placed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Total Jawline Enhancement with Custom Implant

Friday, January 20th, 2017

 

Background:  The approach to improving the shape of the lower face has evolved beyond just chin augmentation. While the projection of the chin still has a valuable role to play in lower facial reshaping, it is not a comprehensive approach to lower facial aesthetics. The shape and size of the entire jawline must be considered.

The single most effective complete jawline augmentation method is by using a custom jawline implant design. While it is made from a 3D CT scan and fits the bone as designed, its effect comes from expanding the entire bony borders of the lower jaw.  Because it covers a broad surface area, its effect can range from a subtle to a dramatic type of facial change.

In some male (and most female) jawline augmentations the patient is seeking a more conservative change. This means that one wants the jawline to be sharper and more angular with modest chin and jaw angle size changes. This is the classic definition of a jawline enhancement as opposed to a major jawline augmentation. To do so the custom jawline implant is often smaller with thin connections between the chin and jaw angles.

male custom jawline implant design Dr Barry Eppley IndianapolisCase Study: This 35 year-old male wanted a stronger jawline but one that was not ‘too big’. He always wore a closely trimmed beard which helped to create the appearance of  stronger jawline. He stated that he would continue to have such a beard after and this had to be factored into the implant’s design and size.

male custom jawline implant design and actual implant Dr Barry Eppley IndianapolisUnder general anesthesia and through a three incisional method (extraoral submental chin and intraoral vestibular incisions), a custom jawline implant was placed. To prevent mental nerve injury it was placed in a midline split two-piece fashion.

Custom Jawline Implant results oblioque view Dr Barry Eppley IndianapolisCustom Jawline Implant result side view Dr Barry Eppley IndianapolisHis after surgery results show a subtle but evident change in the appearance of his lower face. Increased chin prominence was evident as was a more defined jawline heading back to the jaw angles on both sides.

Custom Jawline Implant result front view Dr Barry Eppley IndianapolisTotal jawline enhancement can be done using a custom jawline implant. Keeping the projections at the chin and jaw angle areas more modest with thin connections between these three jawline points can keep the jawline augmentation effect more limited and create a more angular jawline.

Highlights:

1) A custom jawline implant affects the entire jawline in a wrap around implant fabrication.

2) Creating three points of augmentation (chin and jaw angles) that are connected can have a powerful effect on the shape of the lower face.

3) A small custom jaw implant provides an increased angularity to the lower face witout making it too big.

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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