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Dr. Barry Eppley

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Posts Tagged ‘jaw angle augmentation’

The Significance of Muscular and Tendinous Attachments in Jaw Angle Implant Surgery

Wednesday, June 17th, 2015


Augmentation of the jaw angle (often referred to as jawline augmentation) is becoming an increasingly popular aesthetic facial procedure. The  recognition that the back part of the jaw as similar aesthetic significance as that of the front part of the jaw (chin) creates a more comprehensive diagnostic and treatment approach to lower facial aesthetic enhancement. While often perceived as being a completely male procedure, and it is definitely more common in men, it also has benefits for some women as well.

Jaw Angle Implant Results oblique viewThe use of jaw angle implants is unique in numerous ways. First, they are two separate implants (bilateral) whose symmetrical placement can be challenging due to surgical access and common asymmetries in jaw angle shapes that many patients have. Second the optimal augmentative effect must be considered as having a multidimensional jaw angle impact. (horizontal, vertical and anteroposterior) While many surgeons and patients think of jaw angle implants as having a ‘width only’ effect, this perception is both inadequate and historic. Vertical lengthening of the jaw angle for many patients is just as important or even more important that of a width increase.

masster muscle in jaw angle implantsBut regardless of the jaw implant’s size and shape correct positioning on the bone is a critical element in getting a good aesthetic result. The key step in jaw implant positioning is elevation of the masseter muscle and its attachments off of the bone. This large quadrangular chewing muscle has two heads that run from the zygomatic arch to the inferior border of the mandible. The larger superficial head is what attaches to the jaw angle and anteriorly along its lower border. It is also along the inferior border where it joins as a tendinous attachment to the medial pterygoid muscle on the inner surface of the jaw. (pterygomasseteric sling) The smaller deeper head of the masseter muscle is largely covered by the superficial head and inserts much higher up along the lateral ramus near the coronoid process.

Jaw Angle Tendon (Stylomandibular Ligament in Jaw Angle Implant Surgery Dr Barry Eppley IndianapolisElevation of the insertion of both the superficial and deep heads of the masseter muscle are critically important in making the subperiosteal pocket for jaw angle implants. Inadequate muscle release will have the implants sitting too high or too far forward…making them close to the incision in addition to having an undesired aesthetic result. The muscle must gently elevated off of the inferior border and there are numerous undescribed tendinous attachments that are important to release to adequately do so. This is of paramount importance when placing vertical lengthening jaw angle implants as 1/3 or even 1/2 of the implant may need to be sitting off of the bone (below the inferior border) to make a well defined jaw angle. In making this type of muscular release it is also important to not completely disrupt the pteryogmassteric sling or masseteric muscle retraction can occur with the creation of a high muscle bulge when biting down after surgery.

Stylomandibular Ligament in Jaw Angle ImplantsOne important attachment to release in jaw angle implant pocket dissection is the stylomandibular ligament. This is a very specialized type of fascia/tendon that runs between the styloid process of the temporal bone down to the posterior border of the jaw angle It usually sits just above the jaw angle point. It is often classified as a temporomandibular ligament but it inserts no where near the joint capsule. Failure to release the stylomandibular tendon can prevent the jaw angle implant from sitting as far back along the angle as it ideally should.

jaw angle release for jaw angle implantsSuccessful jaw angle implant surgery requires releases of muscular and tendinous attachments alone the posterior and inferior border of the jaw angle area. (red area in illustration) Failure to do prevents seating of the implant over the jaw angle area which is the fundamental purpose of the surgery. This is the most frequent cause of jaw angle implant malposition and is usually due to blind blunt dissection. Without a headlight and electrocautery to release these attachments the risks of jaw angle implant malposition and asymmetry are significantly increased.

Dr. Barry Eppley

Indianapolis, Indiana

Shaping The Male Face

Monday, October 17th, 2011

Superman has been an American cultural icon since he first appeared in comic books back in 1938. His appearance is absolutely distinctive, most notably that of his red, white and blue colors and the stylized S shield on his chest. The shield is so symbolic of his character than its appearance alone immediately brings image of the comic character.

But beyond the colors and the symbol, many of his other features are particularly iconic of what masculinity and attractiveness is supposed to be. His face is absolutely chiseled and proportioned and exudes strength and power. Such Man of Steel facial features appear to have galvanized one male fan to undergo numerous plastic surgery procedures to try and look like this popular superhero.

Hebert Chavez, a superfan of Superman from the Phillipines, has dramatically altered his face to look more like Superman. New agencies have reported that he has undergone a series of operations since 1995. These have included a chin implant to get a strong chin with a cleft, nose reshaping, injections for fuller lips, cheek and jaw implants and eyelid surgery. As bizarre as this sounds, his surgical results actually look pretty good and not as unnatural as one would think.

Such a plastic surgery story brings to mind another face changer, Michael Jackson, and there is no doubt that they both share the similar malady of Body Dysmorphic Disorder. In this mental illness, a person can’t stop thinking about how their appearance is flawed and that perfection is just a surgery away.

But beneath these extreme cases of facial plastic surgery lies some basic truths about what makes a male face more appealing. It starts with an overall facial shape that has more definition and a square to inverted triangular shape. The three bony highlights of the male face are the chin, cheeks and jaw angles. Some degree of prominence in all of them is important to create a sense of overall angularity. Therein lies the frequent use of chin, cheek and jaw angle implants to create those prominences if they are weak, flat or recessed.

In the more lean male face, creating these prominences with implants alone may be adequate. As the chin, cheek and jaw angles become more visible, the non-bony supported areas (submalar and lateral face and neck) will appear more concave as the amount of subcutaneous facial fat in these areas is thin. In the rounder or fuller face, however, some fat removal will need to be considered. This could include procedures such as buccal lipectomies, lateral face and neck liposuction to try and change a convex shape in these areas to at least one that is flat or ideally a little bit concave.

Not every male face can be made more ‘super’. These facial plastic surgery techniques work best in a face that is not too overly round or thick. Such facial shapes are the kryptonite for obtaining the well defined male face that is deemed in both comic books and in real life as desireable.

Dr. Barry Eppley

Indianapolis, Indiana

Three-Dimensional Jaw Angle Augmentation

Saturday, March 13th, 2010

Jaw angle implants have become a more common procedure for men in the effort to achieve a stronger and more defined mandibular shape. By highlighting the jaw angles in combination with a more prominent chin, a triangular lower facial shape is seen from the frontal view. By increasing the divergence of two lines that follow the jawline from the chin back, jaw shape becomes increasingly more masculinized. There is a point at which this divergence is too great and the jaw shape can look  more cartoonish than natural, but this only happens when the jaw angle sticks out further than one’s ears.

This frontal view of the jaw angle oversimplifies, however, the three dimensional shape of this facial area. Because the jaw angle is formed by both horizontal and vertical ramus bone segments, it’s vertical height has a significant impact on how increasing the lateral expansion of the angle will look. A high mandibular angle shortens the face and increases the downward plane of the jaw. A lower mandibular angle lengthens the face and levels out the jaw plane angle. Which one of these jaw angle heights may offer an aesthetic benefit for anyone is based on the other dimensions and shape of their face.

It is important for any patient considering jaw angle augmentation to consider vertical elongation as well as increased lateral protrusion. Besides achieving the best look for a patient, knowing whether this desired angle change is needed changes the type and style of jaw angle implant chosen. Jaw angle implants come in a variety of styles from several different manufacturers. But they fundamentally differ in providing just lateral fullness to your existing angle or both lateral fullness and vertical elongation, dropping the jaw angle lower.

Most lateral only jaw angle implants are made of silastic or firm but flexible polymerized silicone.  Because it has a very smooth and slippery surface, it is not a good material for dropping the jaw angle lower. Even if a curved or notched area exists at its lower edge, it will not stay in position as it easily slides upward by the force of the overlying masseter muscle. More ‘three-dimensional’ jaw angle implants are made of Medpor or porous polyethylene. Their textured and rougher surface offers higher frictional resistance against the bone and are less prone to upward migration. While this is surface biomaterial characteristic is more favorable, I do not trust it enough to not use screw fixation to prevent after surgery migration.

Lowering the jaw angle also causes it to acquire a more 90 degree or square shape versus a more open angle (greater than 90 degrees) when it is higher. This is a profile jaw aesthetic that can be gender-specific. A lower jaw angle means more masseter muscle and a flatter jaw line from front to back, a more masculine facial feature. A high jaw angle reduces the amount of bone for masseter attachment and placed the jaw angle point above the horizontal plane of the chin. This can be more feminine in appearance.

Jaw angle augmentation is more than just about widening the jaw. It requires three-dimensional planning  and proper implant selection to get the desired result. 

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions about Jaw Angle Augmentation (Implants)

Wednesday, February 10th, 2010

1.      Who would benefit from jaw angle augmentation?


The shape of one’s jaw is influenced by its horseshoe or U-shape. From angle to angle, the lower jaw (mandible) is a curved bone that is most recognized by its frontal prominence, the chin. But recent trends in men have placed new emphasis on the aesthetics of the jaw angle. From famous actors like Brad Pitt to male models, a prominent jaw angle and jaw line cast an image of masculinity and virility.


While the benefits of chin augmentation have long been recognized for balancing one’s face seen in profile, enhancing the jaw angle helps the face from a frontal perspective. Flaring the jaw angle outward and making the jaw angle more square (angular)makes the entire jaw line a more prominent facial feature.


Weak jaw angles are evident if the lower face is narrow and the cant of the jawline is steep (oblique) rather than more horizontal. If the point of the jaw angle sits above the point of the chin, jaw angle augmentation may be aesthetically beneficial.  


2.      Are there special implants just for the jaw angle?


Like all facial bony highlights, there is a unique shape to them. The jaw angle is no different. It requires a specially-shaped implant that can provide a widening (lateral projection) and/or a lowering. (inferior projection) There are a variety of different jaw angle implants amongst several manufacturers. Some provide more lateral projection, other more inferior projection. The most common jaw angle implants usually provide a bit of both projections. In each specially-designed shape, there are different sizes as well.


3.      What are jaw angle implants made of?


There are two basic materials from which jaw angle implants are manufactured. These are silastic (silicone)and Medpor. (polyethylene) Each has some different handling properties which affects the flexibility and stiffness of the implants. While they are all chemically and structurally different, the body sees them all the same way…as a foreign material which it tolerates by surrounding it with scar tissue. (capsule)


Different plastic surgeons may have their preference but that choice is not based on whether it is a ‘better’ implant material. It is a function of what they are familiar with and have had good handling and placement experiences. For me, I am more interested in the shape of the jaw angle implant and how it matches the patient’s jaw angle need. The material from which the jaw angle is made is not as important as its shape.


4.      How are jaw angle implants placed?


Access to the jaw angle is done from inside the mouth. This is the most direct route underneath the masseter muscle to where the implant needs to go without creating any external scar. While it is certainly possible to place the implant through an incision right below the jaw angle (as in mandibular fracture repair), this would not only leave a scar but would be more painful and disrupt more muscle tissue.


Through an incision behind the posterior molar teeth along the ascending ramus of the jaw, the bone and the front edge of the masseter muscle are immediately found. Most of the entire masseter muscle must be lifted off the bone to properly place the jaw angle implant into the correct position.


5.      What keeps the jaw angle implant from shifting around after surgery?


Proper positioning of the jaw angle implant is the most important factor in keeping it from moving around after surgery. Silicone, which is very smooth and slick, is much more likely to shift from its intended position than Medpor which has a much higher frictional (gripping) surface. Regardless of the material, I always secure it with a screw when possible to eliminate any doubt about potential implant migration.


6.      How painful is jaw angle augmentation after surgery?


Because it is a submuscular (under the muscle) operation, there is some significant discomfort and swelling afterwards. More pertinently, every patient will have some difficulty opening one’s mouth very wide for several weeks after. Known as trismus, this is the direct result of pain and stiffness from the traumatized muscle. When comfortable, patients should start on range of motion exercises to resume their normal oral opening as soon as possible.


7.      Can jaw angle implants be done with other facial surgeries?


It is common to do jaw angle augmentation with other facial surgeries. Most commonly, this would be chin and cheek augmentation and rhinoplasty. But it can be done with any other desired facial or body plastic surgery procedure.

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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