Background: Creating a slimmer lower face can be done by a variety of bony and soft tissue reduction procedures. When the size of the lower jawbone is the major part of the lower facial fullness, v line surgery is the most known and successful surgery for reducing it. While there are different types of v line surgery the most aggressive and reductive form is a combined vertical removal of the jaw angles/line combined with a t-shaped genioplasty.
Like all facial structural altering surgeries there will be some patients who develop surgical regret. V line surgery is no different. These patients can never adapt to their new face change despite the significant slimming effect that has been obtained. Whether they desire partial or complete reversal of the surgery the question then becomes how best to do it.
When it comes to v line reversal surgery there is one good way to do it and many not so good ways to do it. The following patient’s story makes that clear.
Case Study: This female underwent the typical v line surgery in Korea. She felt that it was overdone and too extreme and desired some degree of reversal. Her 3D CT scan showed her initial v line surgery result.
She underwent a jawline restoration procedure by another surgeon using multiple crafted ePTFE (Goretex) blocks to create a six-piece implant to wrap around the jawline and across the chin. She was unhappy with this result and it did not restore her jawline at all and made her existing jawline wider. A 3D CT scan showed the placement of all the ePTFE implants (highlighted in green) which did not provide any vertical lengthening restoration along the jawline but merely made it wider. The jaw angle implants were not placed over the missing jaw angles but over the existing remaining anterior ramus.
Using the same 3D CT scan a one piece custom jawline implant design was done with the specific objective of putting back the missing jaw angle/line bone all the way into the chin. Like all v line reversals what is needed is largely vertical, creating an implant that puts back the vertically removed. Whether this is partial or complete restoration depends on what the patient wants to achieve and what is believed to be the original jawline shape.
Creating the vertical dimensions of the jawline implant depends on whether the patient wants a subtotal or a total jawline restoration. Regardless of that choice without an original preoperative 3D CT scan (which is almost never available) one has to estimate the vertical lengths needed.
To appreciate the difference between the existing multiple piece ePTFE implants and the current custom one piece design an overlay of the two are shown. (ePTFE = green color, custom implant = teal color)
Under general anesthesia and through her existing external submental and intraoral incisions/scars, the ePTFE implants were freed up and removed. The differences between the removed ePTFE and the custom jawline implant provided a better appreciation of the differences between the two approaches than even on the implant design files.
The custom jawline implant was inserted in a front to back direction as a single piece implant. It was secured with one screw at the chin and two screws at each jaw angle.
The need for vertical jawline restoration from v line surgery is not how most surgeons are familiar with how to augment the jawline. (which is usually width) Adding vertical length to the jawline poses challenges for both implant design and placement for which only a custom implant design can comprehensively to do so.
Case Highlights:
1) Partial or total reversal of prior v line surgery requires vertical elongation of most of the jawline which can only be done by an implant.
2) Trying to create a multipiece jawline restoration using a handcrafted implant approach isa conceptually flawed approach that not only will not work but makes any further revisional surgery more difficult.
3) A custom single piece jawline implant using a 3D CT scan is the most accurate method of reversing the removed bone from prior v line surgery.
Dr. Barry Eppley
Indianapolis, Indiana