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Dr. Barry Eppley

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Posts Tagged ‘jaw angle reduction’

Case Study – Jaw Asymmetry Correction

Sunday, September 27th, 2015


Background: Facial asymmetry is not uncommon and can occur from multiple causes. One of the most common is that from plagiocephaly where the entire craniofacial skeleton rotates or twists around a central axis resulting in a classic pattern of skull and facial bone asymmetries. But most facial asymmetries do not have such well identified causes and are usually idiopathic….it is just the way the face developed.

Jaw or mandibular asymmetries are one of the most common and identifiable anatomic causes of facial asymmetry. The size of the lower jaw and the importance of the chin and jaw angles on facial appearance can make even small jaw asymmetries very noticeable. Jaw asymmetries come in a wide variety of types but most commonly it presents when one side of the jaw has either overgrown or one side has under developed. This results in a twisting of mandible such that the chin is deviated either towards the smaller side or away from the overgrown side.

Many jaw asymmetries are associated with a malocclusion (bite that is off) which is best treated by a combined orthodontic and jaw surgery combination. But when the bite is acceptable or the patient does not want to undergo orthognathic surgery, aesthetic correction of the jaw asymmetry can still be done.

Jaw Asymmetry 3D CT scan front view Dr Barry Eppley Indianapolis Jaw Asymmetry 3D CT scan Dr Barry Eppley IndianapolisCase Study: This 22 year old male has lower facial asymmetry with a smaller right side, a chin deviation to the right and a more pronounced left jaw side/angle. A 3D CT scan shows that the right mandible was shorter and the left  mandible was longer. This created the chin deviation to the right of the facial midline.

Cin Osteotomy for jaw Asymmetry Dr Barry Eppley IndianapolisUnder general anesthesia he had a left jaw angle reduction, a right jaw angle implant placed (width only jaw angle implant) and a leveling chin osteotomy. All jaw procedures were done from an intraoral approach. Reduction of the left jaw angle accounted for a 5mm narrowing of the jaw angle flare. A 7mm wide lateral jaw angle implant was placed on the right. The intraoral chin osteotomy consisted of an asymmetric wedge  removal and shifting of the chin bone back towards the midline.

Jawline Asymmetry Correction result front view Dr Barry Eppley IndianapolisJawline Asymmetry Correction result oblique view Dr Barry Eppley IndianapolisHis jaw asymmetry correction surgery showed a good improvement. In an ideal world I wish just reducing the larger jaw on the left side of his face would straighten it but that almost never can happen by itself. The reason is that you can not reduce the larger bone enough to make a big difference. (there are teeth and nerves in the bone so that is a limiting factor as to how much bone can be reduced) For these reasons this is why most jaw asymmetry corrections must employ a ‘three point’ approach. This means all three points of the jaw (chin and two jaw angles) are treated. Reducing the left jawline, straightening the chin and augmenting the right jaw angle in this case provides the most comprehensive approach to jaw asymmetry correction. Even with this approach perfect lower facial symmetry is not usually possible. But it is usually the best approach to mask the lower facial disproportion which now exists.


1) Jaw and lower facial asymmetry is a developmental deformity that usually affects the entire jawbone from angle to angle.

2) It is rare that just treatment of one side of the jaw asymmetry will result in a very good correction.

3) Jaw asymmetry correction is best done by treating the three points along the jawline, the chin and both jaw angles.

Dr. Barry Eppley

Indianapolis, Indiana

Three-Dimensional Jaw Angle Surgery

Saturday, July 4th, 2015


Changing the mandibular jaw angle can be one of the most challenging of all aesthetic facial skeletal surgeries. It is a tight space to work in from an intraoral approach and visualization is almost always suboptimal. Loupe magnification and a head light would be considered critical in any type of jaw angle surgery particularly that of bone reshaping/reduction.

Jaw Angle OstectomyWhile jaw angle reduction is not a commonly performed aesthetic procedure in Caucasians, it is extremely common in Asians who frequently have a more square face with prominent jaw angles. Thus there have been many variations in the Asian plastic surgery literature as to how to perform an ostectomy of the jaw angles. Given the difficulty in performing the procedure there is no universally described method that can completely avoid uneven or asymmetric posterior mandibular contours.

In the July 2015 issue of the Annals of Plastic Surgery, the article entitled ‘Endoscopic-Assisted Intraoral Three-Dimensional Reduction Mandibuloplasty’ was published. In this paper the authors describe a jaw angle reduction technique done in over 100 patients over a three year period. This was a one-stage long-curved ostectomy combined with a splitting corticectomy done through an intraoral approach with the assistance of an endoscope. The one-stage long-curved ostectomy and corticectomy were performed using an oscillating saw with angles of various degrees and length under direct vision. Their results showed good three-dimensional changes to the jaw angle with lower facial width reduction. Patient satisfaction was high. These changes, as would be expected, increased the height of the gonial angle and the mandibular plane angle as well. No major complications occurred from bone fracture to facial nerve injury.

The value of the endoscope is not clear from reading this article but what is most evident is that effective reduction of the jaw angle requires a combination of bony techniques. The actual jaw angle must be removed and the bone thinned by removing the outer bony cortex. This can make the face look thinner from the front view and have a smooth line from the side view. The jaw angle will get higher and there is the risk of loss of some soft tissue support so over resection of bone should be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female V-Line Jaw Narrowing Surgery

Tuesday, March 24th, 2015


Background: Jaw or jawline reduction surgery is directed towards narrowing the lower third of the face. Very square or wide lower faces is either considered too masculine or aesthetically undesired in women in particular and in some men. While widely considered an Asian (particularly Korean) type surgery, it is becoming more commonly requested amongst Caucasians as well to help slenderize their face.

There are non-surgical and surgical methods for jaw reduction (so called V-line jaw surgery) based on the anatomy of the mandible and its soft tissue attachments. A wide lower face can be caused by masseter muscle enlargement due to congenital development or bruxism and is treated non-surgically by Botox injections. Masseter muscle reduction is often a necessary part of jawline narrowing but mandibular bone changes are usually the cornerstone of V-line jaw narrowing.

Inferior Alveolar nerve in Jaw line Narrowing Dr Barry Eppley IndianapolisIn narrowing the jawline it is necessary to create the visual effect of a less wide mandible from angle to chin. While it is commonly perceived that the bone is cut from the sides of the jawline from back to front, this is not how it is actually done. The location of the inferior alveolar nerve in the mandible as it courses through the bone and its exit from the mental foramen anteriorly make such a bone reduction approach surgically very difficult with a high risk of nerve injury. Thus most commonly chin and jaw angle bony procedures are done to create the v-line jaw narrowing effect,

Case Study: This 21 year-old female wanted multiple facial reshaping procedures done. One of her main areas of focus was her wide lower face and shorter chin. V-line jaw narrowing surgery was planned.

Jawline Narrowing Surgery result front view Dr Barry Eppley IndianapolisUnder general anesthesia, she initially underwent bilateral jaw angle reduction by outer cortical osteotomies combined with electrocautery of the inner surface of the masseter muscle. A horizontal chin osteotomy was then done with a 5mm midline ostectomy with a horizontal advancement of 7mms.

Jawline Reshaping result oblique viewJawline Reshaping result side view Dr Barry Eppley IndianapolisThree months after her V-line jaw narrowing, she showed a more narrow jawline in the front view and a longer jawline in the side view. Additional Botox injections will be done in the masseter muscle for further thinning in the jaw angle area.

In most V-line jaw narrowing surgeries, the body of the mandible does not need to be reduced to create the effect. Chin and jaw angle changes are enough in most cases to create an adequate jawline narrowing result.

Case Highlights:

1) Jawline reshaping typically strives to make the jawline more narrow and longer in the front view.

2) Most jawline narrowing techniques involve an anterior bony genioplasty and a posterior angle/ramus reduction.

3) As the chin becomes less wide (and sometimes vertically longer) and angles become less wide, the jawline becomes perceptibly more narrow and v-shaped.

Dr. Barry Eppley

Indianapolis, Indiana

Masseter Muscle Changes After Jaw Angle Reduction

Tuesday, September 2nd, 2014


Jaw angle reduction surgery, technically known as reduction gonioplasty, is a well known procedure to help reduce a square lower face. It is particularly common in Asians who often have more of a wider face with thicker masseter muscles and greater posterior jaw bone width. It has been practiced for years and is often part of other facial reshaping procedures with the goal of an overall thinner face.

Jaw Angle Reduction (Removal) Surgery Dr Barry Eppley IndianapolisJaw angle reduction surgery can be done by one of two techniques, a oblique ostectomy (amputation) and a sagittal reduction. (outer table ostectomy) Each has their own advantages and disadvantages with an ostectomy being a more aggressive bone reduction method than an ostectomy. But either jaw angle reshaping techniques involves the need to raise the masseter muscle off the bone to perform the surgery. What effect this has on the long-term result has never been studied. Although it has been hypothesized, based on other jaw angle surgeries, that some muscle thinning effect may occur as well due to muscle trauma and disinsertion.

In the September 2014 issue of the Journal of Craniofacial Surgery, an article appeared entitled ‘Long-Term Changes in the Masseter Muscle Following Reduction Gonioplasty’. In this paper, 56 patients were studied before and four years after jaw angle reduction surgery with 3D CT scans. The changes in the volume and shape of the masseter muscle were analyzed. Their results showed that the masseter muscle shrunk an average amount of 21% in the lower part of the masseter muscle in long-term follow-up.

This study confirms what would be suspected with elevating the masseter muscle for any surgery, whether it be jaw angle reduction, jaw angle implants or sagittal split osteotomies. Elevation and disinsertion of the muscle results in some degree of atrophy and loss of muscle bulk afterwards. This can potentially create a skeletonization of the jaw angle area which may account for some of the facial narrowing effect. This could have a positive or negative effect on the jaw angle reduction result depending upon how much bone is removed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Lateral Corticotomy Jaw Angle Reduction

Monday, October 21st, 2013


Background: The frontal view of the face allows one to see its width from the forehead down to the jawline. This width and its proportion to the length of the face helps create an  overall facial shape. It is generally acknowledged that there are seven basic facial shapes which for women an oval shape is more aesthetically desired while for men a more square shape may be preferred.

But to create a slimmer or more oval-shaped face, narrowing of the lower face is often needed. While Botox can be used to reduce the thickness of the masseter muscle, narrowing the underlying bony jaw requires surgery. Most of the width of the bony jaw  is located in its back half, technically known as the ramus of the mandible. Due to the natural divergence of the jawline from the chin on back, the jaw angles make up the widest part of the lower face.

Reduction of the jaw angles is a well known surgical technique that is used for narrowing a wide lower face, most commonly done for Asian facial reshaping. Historically, jaw angle reduction was an amputation method removing the entire angle in an oblique fashion. While that may be effective in some patients, it is often a technique that is overused and can create undesired aesthetic consequences. (tissue sagging, steepening of the mandibular plane angle) This has led to less aggressive techniques where the angle shape is preserved and its thickness is reduced by a lateral corticotomy.

Case Study: This 33 year-old female was having multiple procedures for facial reshaping. One of the changes she wanted to make was a narrowing of her lower face. But she did not want to lose the shape of her jaw angle and did not want a ‘traditional’ jaw angle amputation technique.

Under general anesthesia an intraoral posterior vestibule incision was made on both sides. The bony angles were exposed. Using a handpiece and burr, the cortical bone was shaved down completely to the marrow space, essentially doing a complete lateral corticotomy on both sides.

The two options for jaw angle reduction are very different in the effects they create. A traditional technique amputates the jaw angle, changing the slope of the mandibular plane as it narrows the bigonial width. Conversely, lateral corticotomy reduction preserves the shape of the jaw angle but has a less significant width reduction.

Case Highlights:

1) Reduction of the posterior lower width of the face involves removal of a portion of the jaw angle…if it has adequate flare or bone thickness.

2) Jaw angles can be narrowed by either a full thickness (amputation) or a partial thickness reduction technique.

3) The width of the posterior lower face is a combination of both bone and soft tissue and bone reduction alone does not always guarantee a very visible narrowing effect.

Dr. Barry Eppley

Indianapolis, Indiana

Asian Facial Reshaping by Cheek Narrowing and Jaw Angle Reduction

Sunday, August 4th, 2013


Reflecting different facial characteristics from distant parts of the world is the difference between Eastern Asian and Caucasian facial bone structures. Prominent cheekbones and a strong jaw angle are common Asian features that are often asked to be reduced as they create a face that is perceived to be wide, square and relatively flat. In the Western world, however, these facial features are highly valued and requests for aesthetic augmentation of the cheeks and jaw angles are common.

Surgical reduction of the cheek and jawline can be done by employing craniofacial bone contouring techniques. But there are limitations as to how much bone reduction can be obtained and the facial changes that will result. Not every Asian face can be made more round, oval or more narrow in width. The thickness of the overlying soft tissues will affect how much reduction of the bone on the outside is seen. In addition it is important for the surgeon to realize that Asians seeking bone contouring surgery are not trying to achieve a Western look but a better shaped face that preserves their ethnicity.

Cheek bone reduction surgery has evolved over the years. Initially simple burring was done on the anterolateral face of the cheekbone through an intraoral approach. This is not only largely ineffective but also can lead to soft tissue sagging from complete periosteal detachment. It is now recognized that an infracture of the zygomatic arch is the only effective method of facial width reduction. (the arch is the culprit not the cheek bone prominence per se) While this can be done very effectively from above under direct vision through a coronal scalp incision, that is a more invasive approach than is necessary. The zygomatic arch can be repositioned by performing a bone cut at the attachment of the front part of the arch to the cheekbone body (zygoma) as well as a second bone cut at the back end of the arch where it attaches to the temporal bone. This moves the convex arch inward, reducing facial width by about 4 to 6mm per side.

Some Asian faces are wider in the upper face not because of the zygomatic arch convexity alone. The width of the temporal area above (bitemporal width) may also be significant and even when zygomatic narrowing is done the results do not make much of a facial change. Bitemporal facial width, contrary to popular perception, is not due to bone but the thickness of the temporalis muscle.  The temporal bone is a very concave bone whose thickness has little influence on the facial width at the side of the eye into the hair-bearing temporal scalp region. This muscle can be reduced by either Botox injections or temporal muscle release and resection through a vertical scalp incision.

Asian faces often have a wider lower face due to a large flare to the jaw angle and thick overlying masseter muscles. To get the best narrowing effect, both muscle and bone must be treated. Resection of the masseter muscle is not a good option and any consideration of that has now been replaced by Botox injections. This requires a series of Botox injections done over a year to produce a sustained muscle shrinking effect.

Contouring of the prominent jaw angle is done from an intraoral approach using several techniques. The traditional approach of a complete amputation of the angle, while , effective, often leaves a high and ill-defined bone shape that may also cause loss of soft tissue support and the development of jowls. The goal is jaw angle narrowing not necessarily jaw angle removal. Burring of the prominent angle, saw reduction in the sagittal plane or an outer cortical bone removal are all better reduction techniques that amputation. Narrowing of the jawline in front of the jaw angle towards the chin can also be done and may be necessary to really show the effects of any jaw angle (bigonial) reduction.

It is very valuable before doing either cheek or jaw angle reduction that presurgical x-rays are obtained. At the minimum panorex and submental digital x-rays are needed. But the drop in cost of 3D facial CT scans and the easy accessibility of them at any outpatient CT center makes their use preferred.

Whether reducing the Asian jaw angle/jawline or the cheek width, it is important to look at how one affects the other. Reduction of a prominent jaw angle can make the cheek prominence look wider and vice versa. This is somewhat similar to the relationship between the nose and the chin. This is why the best Asian facial narrowing effect comes from simultaneous reduction of both cheek and jaw angles in many patients.

Dr. Barry Eppley

Indianapolis, Indiana

Mandibular Gonioplasty – Jaw Angle Removal vs. Jaw Angle Reduction

Wednesday, April 13th, 2011

The shape of the lower jaw has an influence on the appearance of one’s face. Besides the shape and prominence of one’s chin in the front, the other important jaw features are that of the paired angles in the back. The more prominent or square the jaw angles are, they can enhance the masculine features ofa man and can give the impression of strength and confidence in a woman. When the jaw angles are too prominent, however, the jaw can be disproportionately wide as compared to the rest of the face. This may create a very square-shaped face and is the motivation for aesthetic jaw angle modification surgery, also known as a gonioplasty. (jaw angles are also referred to as the gonial angles)

Jaw angle bone modification is done to soften the face and make for a less square or more oval-shaped face. Some may call this creating a more feminine jawline and this is certainly true for a woman considering the procedure. Fewer men undergo gonioplasties because the square jaw is a desired masculine feature but there are some men whose jaw angles are exceptionally prominent who want modification as well.

When considering jaw angle modification, it is extremely important that one understand that there are different techniques for doing it…with different aesthetic outcomes. The traditional and most commonly used method is jaw angle removal surgery. This is always referred to as jaw angle reduction but this is a misnomer. Reduction implies the bony angle is preserved but reduced. In reality, the entire jaw angle is simply cut off or removed. From incisions inside the mouth, the junction of the back part of the jaw and the lower border of the jaw is essentially cut off. This not only softens the jaw angle but also raises the line of the jaw from front to back.

For many women, the elimination of the jaw angle (and raising the height of the back part of the jaw up to a horizontal level of the mouth) is aesthetically advantageous because it is a feminizing procedure. It is also the most effective way to thin the width of the face (jaw angle to jaw angle) because the full-thickness of the jaw bones in this area are removed. Given that that each jaw angle is 1 cm or more thick, one can narrow the lower facial width by up to 2.5 cms. For men, however, the total loss of the jaw angles may be aesthetically advantageous and must be carefully considered. I have consulted more than one man who wanted jaw implants to replace jaw angles that have been cut off.

The other technique for gonioplasty is true jaw angle reduction. In this technique, the jaw angles are not cut off but thinned by burring reduction. The shape of the jaw angle is preserved but the bone is thinned. Its advantage is that the jaw angle is not eliminated or raised but its disadvantage is that it can not achieve as much narrowing. This is because the full thickness of the bone is not removed but thinned. This changes the amount of transfacial width reduction at the jaw angles to maybe 1 to 1.5 cms.

In lower facial gonioplasty, the two available techniques are removal (excisional gonioplasty) and reduction. (reduction gonioplasty) Their effects on the jaw angle and the amount of width reduction are different. The use of the term ‘jaw angle reduction’ is often misunderstood and may lead to undesired jaw shape outcomes if done in a standard fashion for every patient. This may lead to some unhappy patients seeking jaw angle implant reconstruction later.

Dr. Barry Eppley

Indianapolis, Indiana

Risks of Jaw Angle Reduction Surgery

Saturday, December 11th, 2010

A recent report out of China was that of a death due to plastic surgery. What was most significant about this report, besides the obvious tragedy, is the procedure which ultimately resulted in the patient’s demiss. While deaths from plastic surgery procedures are extremely uncommon and have been reported in the past, most involve a cosmetic operation done on the body.Such lethal occurrences are even more rare in plastic surgery of the face.

A young prominent 24 year-old female (she was an aspiring pop singer who was on China’s equivalent of ‘American Idol’) died in November while undergoing ‘facial-bone grinding surgery’. According to the report, her jaw bleed uncontrollably at some point in the operation which lead to it accumulating in her throat. This blocked her ability to breathe and she subsequently suffocated and died.

What was this ‘facial bone grinding surgery? This does not sound like a very common cosmetic facial procedure and why would anyone have their facial bones ground on? While I don’t know any of the details of this specific surgery, it could only be that of a jaw angle reduction procedure. While very rarely requested or done in Caucasian patients and in the U.S., it is actually a fairly common cosmetic facial procedure in the Asian patient and in countries such as Korea and China. In the desire to have a more slim and less broad face, narrowing the prominent jaw angle is one facial procedure that helps achieve that goal. It is not usually done by grinding or burring of the bone but by actually cutting off the angle of the jaw bone with a saw. One of the known potential complications, albeit rare, is to inadvertently cut one of the large blood vessels to the surrounding masseter muscle which envelopes the bone. This may cause a lot of bleeding but it isn’t usually a lethal complication.

How is it possible for this young lady to have suffocated from the bleeding during her surgery? This could only have happened from the type of anesthetic she was having. Always in my hands, this isan operation that is done with the patient fully asleep (general anesthetic) and having their airway protected by an endotracheal tube. This breathing tube not only makes sure that one’s airway does not get blocked but also prevents any fluid that would enter the throat from being allowed to get into the lungs. For her to have suffocated from the bleeding, she must not have had a breathing tube in a place. This also means she was done under some form of local or sedation anesthesia…an almost unthinkable notion for this kind of surgery. Besides patient comfort, a general anesthetic with a protected airway also helps ensure patient safety should bleeding events like this one should occur.

Like many tragic outcomes from cosmetic procedures, close inspection of the story often bears out that uncommon and unusual approaches were being done. Taking shortcuts in cosmetic surgery should never over ride patient safety measures.

Dr. Barry Eppley

Indianapolis Indiana

Facial Bone Reduction Surgery

Monday, February 1st, 2010

Changing one’s bony prominences is the primary method for altering the shape of the face. The face is composed of a variety of bones which have convex and concave contours. The external appearance of the face is highly influenced by the convex bone contours. From the brow bone down to the long curvilinear shape of the mandible, there are numerous key bony projection points. (e.g., cheeks, chin, jaw angles)

Most commonly, a variety of plastic surgery operations exist to enhance or increase their projections. Chin, nose, cheek and jaw angle implants are prime examples. It is almost always easier to increase facial bone projection by adding to the bone rather than actually moving the bone.  There are also, however, operations that work in reverse…to reduce or deproject these very same prominences.

Facial bone reductions are not as well known and are less commonly done. Unlike augmentations, facial reduction procedures require modification or shortening of the bony prominences. While some can be shaved down, others require actual cutting off or out of bone sections to change the amount of bony projection.

Brow bone reduction is requested when the brows have a very prominent or ‘Neanderthal’ appearance. Mainly this procedure is done in men and in male to female conversions. (facial feminization surgery) This must almost always be done through a frontal hairline or scalp incision. In some cases, the brow bone may be simply burred down but this is unusual. The underlying frontal sinus occupies much of the width of the brow bone so the overlying bone is quite thin. Only if one is modifying the tail of the brow can it be just burred down. The outer table of the frontal sinus must be removed, reshaped, and then put back with tiny plates and screws. The scar from the incisional approach is the key decision in deciding to undergo this operation.

Cheek reduction is about modifiying the front edge of the cheek bone and its arched form back to where it attaches to the temporal bone. Most patients that want cheek reduction are often Asians in an effort to improve their wider face appearances. A vertical bone cut is made through the body of the malar bone and a wedge of bone is removed. The reduced cheek bone is then attached to the maxilla with a four-hole plate and screws. To get the more posterior part of the arch to move inward, the thin attachment of the posterior part of the zygomatic arch is cut with an osteotome and allowed to move inward (by muscle pull) without the need to secure it.

Nasal reduction is achieved by conventional rhinoplasty techniques. A significant part of a nasal hump is actually cartilage and not bone. The key in reductive rhinoplasty is not to overdo it, creating a saddle nose or pinched upper and middle vault appearance. This can result in nasal airway breathing difficulties. When it comes to helping a face look less wide and more sculpted, the nasal dorsum often is better elevated and not reduced.

Chin reduction is done by burring down the genial prominence. While this bone area is simple to get to through a submental incision, chin reductions are notoriously prone to cause soft tissue problems if not done correctly. This is the only facial bony prominence where the soft tissue does not just ‘snap back’ over the bone. If the excess skin and muscle is not removed and readapted back to the reshaped bone, it will sag resulting in the classic ‘witch’s chin deformity. Also, unlike chin bone advancements which can be brought forward 10 to 12 mms or more, retropositioning of the chinbone can not be done as dramatic and is more in the range of 4 to 6mms at best. Going back further than that can have adverse effects on the neck causing undesired fullness.

Jaw angle reduction is most commonly done in Asians like cheek reduction. Through an incision inside the mouth, the angle of the jaw is blunted by an oblique bone cut removing the prominent tip. How much of the tip or angle area is removed is a matter of intraoperative judgment. There is a fine balance between removing too little and completely having no angle at all. A nearly straight line from below the ear to the chin is not desireable either. This is the most uncomfortable of all the facial bony prominences to reduce because the large master muscle must be raised, causing considerable swelling after also.     

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

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





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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