Background: V line surgery is the most aggressive and effective form of aesthetic jaw reduction. It is not an easy surgery to perform as the angle of the bone cuts from an intraoral approach can be difficult to make from the jaw angles coming forward to the chin in a perfectly symmetric fashion. With this amount of three-dimensional jawbone removal the shape of the lower face can be dramatically changed.
Besides its technical challenges patient selection is also important for a successful V line surgery outcome. The operation was designed for reduction of the large jawed patient which needs this amount of bone removal. However when done on average sized jaws the reduction result can be too dramatic and the lower face smaller than the patient may have anticipated. It is simply not an operation for those patients seeking discrete or modest reductions of their lower jaw.
For the patient who has had an overdone V line surgery the only method of subtotal or total reversal is a custom jawline implant design. The key question in such designs are tw-fold: 1) is it a complete or partial jawline implant design, and 2) what are its various thicknesses and shape regardless of a complete or partial jawline implant design. It is also important to remember that there was a reason one had the surgery initially so it is important to not make an implant design that is too big.
Case Study: This patient had a V line surgery that left the lower jaw smaller than desired with an unusual shape. His 3D CT scan showed that the jaw angle cut was too steep and amputated it off at 45 degrees. The chin had a completely vertical wedge removal reduction with a chin implant placed in front of it. The body of the mandible between the chin and jaw angles was left untouched.
A custom jawline implant was designed to restore some shape to the jaw angles and some vertical length along the jawline and chin with just a little more horizontal projection.
Under general anesthesia and through the existing intraoral incisions and a new submental skin incision the custom jawline implant was successfully placed.
When seen four months later he has a visible improvement in his jawline but came to realize that it looked more masculine than he wanted.
He concluded that it was the chin and jawline in front of the angles that was too wide. As a result he subsequently has that part removed and a new standard chin implant placed.
This case was interesting for two reasons. First this was a really unusual of V line surgery which probably reflects the inexperience of the surgeon performing it. The angle of the jaw angle cut was too steep and did not run forward to the chin. This left the intervening part of the jawline, the body, completely unchanged. Rather than doing an inverted T-shaped genioplasty, which is a routine part of many V line surgeries, the chicken was vertically reduced and I smile implant placed in front of it. Again this represents the lack of technical skill and the inexperience of the surgeon.
This left him with a very visible jawline deformity both in the amount of reduction and in the resultant shape of the lower jaw. A custom jawline implant was the correct solution for reconstruction but in hindsight, what inevitably what inevitably became the ultimate implant design after the second surgery, is now evident after the fact. Since the middle portion of the jaw never changed it now makes sense that no augmentation of that area was ever really need it. The residual chin may have been deficient but this was in the horizontal direction only. This speaks to the importance in custom jawline implant reconstruction of V line surgery to not over correct. Records in every direction
Key Points
1) An overdone V line jaw reduction can only be partially or fully reversed by a custom jawline implant.
2) The 3D CT scan in this case showed a most unusual V line surgery bone cut result.
3) In using custom jawline implants for jaw reconstruction there is a delicate balance between enough vs too much jawline restoration.
Dr. Barry Eppley
World-Renowned Plastic Surgeon