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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘chin osteotomies’

Corrective Surgery for Lower Facial (Jaw) Asymmetry

Saturday, November 21st, 2009

Facial asymmetry is generally the norm, not the exception. The same may be said to be true for any paired body part. Few people have identical facial halfs but most such asymmetries are minor and essentially undetectable. With the asymmetry becomes more than minor (greater than five millimeters or more), however, it may become apparent to more than just the casual eye.

One of the most common reasons for facial asymmetry is the mandible or lower jaw. In my experience, I consider it the most likely facial bone to develop differences between the two sides during growth. This most likely is because of its hinged or joint attachments (TMJ) to the skull where jaw growth is highly influenced by condylar development. Any injury, even minor, to the condyle during growth can cause bone developments differences between the two sides.

When the lower jaw is not symmetrically developed, it can be quite apparent with obvious facial asymmetry and a potential malocclusion. (poor bite) More frequently, however,  the face and jaw may be asymmetric but one’s occlusion has good interdigitation. There are many known causes of mandibular asymmetry including a superior altered cranial base (craniosynostosis, torticollis, deformational plagiocephaly), condylar deformities (fractures, hyperplasia, hemifacial microsomia, arthritic degeneration) and external compressive deformation from overlying tumors causing a mass effect.

Most commonly, however, I see mandibular-based facial asymmetries in adults which do not have a clearly identifiable cause. Regardless of the reason, known or unknown, the diagnosis only matters from the standpoint of understanding where and how the mandible is asymmetric. While 3-D CT scans make great pictures and clearly show the problem, I find that a panorex film is just as helpful. It allows for tracing and precise measurements of the vertical height of the ramus, the differences in the inferior border of the mandible from side to side, and the symmetry of the two chin halfs.

When mandibular asymmetry exists with a bite discrepancy or significant cant to the face, strong consideration should be given to a combined treatment plan of orthodontics and corrective maxillary and mandibular osteotomies. This will produce by far the best long-term solution. However, for those patients that do not want or are not capable of going through this program or for more minor asymmetries, a camouflage treatment can be done.

Camouflage treatments for any form of facial asymmetry is largely based on using bone implants for augmentation or removing bone for reduction.  For the short posterior (back part) of the mandible, the use of jaw angle implants can be very useful to made it wider or longer…often both are needed. Those jaw angle implants which extend or wrap around the lower border are particularly useful as well as more stable. When the ramus is too long, jaw angle and inferior border ostectomies (bone removal) can be done to better match the other side. Both approaches are done intraorally.

When the asymmetry involves the chin implants are not usually the best option. Cutting and leveling the chin bone (one side reduction or expansion) is usually more effective and a better long-term solution.

Significant correction of mandible-based facial asymmetries can be done by a combination of jaw angle and chin manipulations. Choosing the best options can be done through a good facial analysis and patient discussion as well as a tracing assessment of a panorex.

Dr. Barry Eppley





Correction of Facial Asymmetry in Adults from Occipital Plagiocephaly

Monday, October 19th, 2009

Occipital plagiocephaly is a well known congenital malformation of the back of the head marked by an oblique slant to the main axis of the skull. It is commonly corrected today by the early institution of either static or dynamic cranial orthotics or helmets. In rare cases if the skull is significantly deformed and does not respond to external molding influences, cranial reshaping can be successfully done.

Plagiocephaly is well known to affect how the face develops. What happens in the back of the skull will influence how the front of the skull and face looks. This occurs in a diametrically opposite manner. The side that is flat on the back of the head will be protrusive on the front….and vice versa. Even in cases where helmet therapy or even surgery has made a well rounded back of the head, the face may still show some of the residual effects as it develops resulting in facial asymmetry. When plagiocephaly goes untreated or was not adequately treated at a young age, this facial asymmetry may become quite apparent.

The facial asymmetry that results from a plagiocephalic influence appears as that of a ‘twisted’ face if one is looking from above. This is apparent by misaligned ears (the ear on the affected side may be pulled forward and down and be larger then the unaffected ear) and facial asymmetry, with the more forward side of the face having a fuller forehead, brow bone, and cheek. The jawbone will be tilted and one’s occlusion (bite) may have a cant to it. There may be differences in the position and shape of the jaw angles and the chin may be deviated toward the ‘weaker’ or more retrusive side.

When the facial asymmetry is very severe, complete facial bone repositioning incorporating orthodontics and multiple jaw orthognathic surgery is needed. But most of such facial asymmetry that I see in my Indianapolis plastic surgery practice is more mild and in late adolescence or adulthood. Patients are looking for less major methods for improving their facial asymmetry.

When one considers improving facial asymmetry, a careful analysis of the face must be done to determine exactly where the imbalances are. Of even greater importance is input from the patient as to which facial prominences they consider to be the good or the bad side. This is very important because weak areas can be built up with implants which is most commonly done because it is easier. But reduction of bone can be done in certain facial areas if they are too prominent.

Options in facial asymmetry correction include from top to bottom: forehead/brow augmentation, forehead/brow reduction, cheek and orbital implants, jaw angle augmentation or reduction, inferior border mandibular ostectomies, and chin osteotomies or implants. Such an array of procedures requires thoughtful and careful preoperative planning. When more than one of these is done during the operation (which is most common), the effects of facial rebalancing can be quite significant. In my experience, at least two or three facial areas are treated at the same time to get the best result.

 While complete or perfect facial symmetry is not obtainable in any case, significant camouflaging of the facial bony asymmetries can be made. Such surgical improvement provides great psychological relief to the facial asymmetry patient and can usually be achieved in a single operation.   

Dr. Barry Eppley

Indianapolis, Indiana

Extreme Chin Augmentation with Combined Implants and Osteotomies

Wednesday, May 20th, 2009

The treatment of a short chin is most commonly done with a synthetic implant. When the chin deficiency becomes larger, some plastic surgeons will move the small chin bone forward (osteotomy) to avoid using a larger chin implant. Both approaches are highly successful for chin augmentation and the use of either one is based on the degree of chin shortness, the surgeon’s experience, and the amount of surgery a patient wants to undergo.

In some rare cases of chin deficiency, neither an implant or an osteotomy are completely satisfactory. The magnitude of the chin deficiency may not allow the chin to come close to the most aesthetically ideal horizontal position. The thickness of the chin bone may be less than the chin deficiency or off-the-shelf chin implant options do not have enough thickness. While custom-designed chin/mandibular implants are one option for this problem, the amount of synthetic material needed may not be savory for some patients or their plastic surgeons.

In such cases of large chin deficiencies, the fundamental problem is always that the overall mandible is short. These patients are best treated by orthodontics and subsequent mandibular advancement osteotomies, with or without additional chin augmentation done at the same time. However, some patients do not have the resources for this standard approach or are seen later in life when they are not willing to undergo that multi-year treatment plan.

One option I have found helpful in my Indianapolis plastic surgery practice in these large chin deficiencies is to do a combination of an osteotomy with an implant in front of it. This type of ‘extreme’ chin surgery gives a horizontal result that is greater than either one alone. Adding an implant to an osteotomized and stabilized chin segment adds little extra time and no extra dissection to the procedure. The implant should be stabilized onto the chin bone with screws as it will easily displace if not done so.

Over the years, I have performed 11 such cases without any postoperative problems. I have observed no infections, implant shifting, or problems with the osteotomy healing. The chin skin will look quite stretched for awhile but it does eventually relax. Feeling to the lip and chin will be affected for awhile, primarily due to the osteotomy, but I have had no long-term complaints about permanent numbness.

Extreme chin surgery is reserved for those patients who cannot undergo proper treatment for a short jaw but still want aesthetic improvement. A large underbite will still exist after surgery. This combination of chin osteotomy/implant offers a less expensive option than a custom-design implant with less implantation of synthetic material.   

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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