ArabIncel

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Below I’ve attached two pics side by side, one being a pic of my current lower third and the other being a morphed pic of what I’d like my lower third to be (so the changes are: a taller and more square chin, and a more angular and slightly wider jaw). Could such a change be achievable via a custom wraparound jaw implant or will I need a custom wraparound jaw implant plus fillers afterwards? Thanks.
 

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rational

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Yes bro. But your current lower third/ jaw is too wide and short to get implants, as your jaw cannot be wider than your the rest of your face/head.

Go to South Korea and get double jaw surgery for less wide and slimmer lower third, then get square jaw implants and you can achieve this.

Whole process will take a year but imo its worth it.
 

ArabIncel

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Yes bro. But your current lower third/ jaw is too wide and short to get implants, as your jaw cannot be wider than your the rest of your face/head.

Go to South Korea and get double jaw surgery for less wide and slimmer lower third, then get square jaw implants and you can achieve this.

Whole process will take a year but imo its worth it.
But I’ve heard that the wraparound jaw implant can be customized such that it does not really add any more jaw width. As you’ll note, the jaw width in the morph barely increased. And I’ve heard it’s possible to customize the wraparound jaw implant so that it doesn’t add any more width BUT does add height among other dimensional changes im after.

But idk too much
 

ArabIncel

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It seems to me after some analysis that in the after picture (the morphed picture) the gonions sit higher up (leveled with the mouth) whereas in the before picture they sit slightly lower. Now as I understand a custom wraparound jaw implant will add size to the body of the mandible, which means that I’ll come out with the gonions sitting lower than they sit in the morph. Does that mean I need a ramus reduction osteotomy before having the implant placed in?
 

Surgerymax

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Below I’ve attached two pics side by side, one being a pic of my current lower third and the other being a morphed pic of what I’d like my lower third to be (so the changes are: a taller and more square chin, and a more angular and slightly wider jaw). Could such a change be achievable via a custom wraparound jaw implant or will I need a custom wraparound jaw implant plus fillers afterwards? Thanks.
Close to that anglularity is probbably possible with an implant alone. Yes you do need some vertical augmentation of the chin and it may be possible a mandibular body reduction.

It is imossibl to give a definite answer especially without a scan - you appear to have the flat occlusal plane look.
 

YourFaceIsYourLife

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Comical lower third height tbh but probably looks better in motion.
 

ArabIncel

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Close to that anglularity is probbably possible with an implant alone. Yes you do need some vertical augmentation of the chin and it may be possible a mandibular body reduction.

It is imossibl to give a definite answer especially without a scan - you appear to have the flat occlusal plane look.
Rather than get a custom wraparound jaw implant + possibly jaw fillers, can I instead maybe opt for a custom chin implant + jaw fillers in order to go for the look I’m aiming for here? This option would be cheaper but I’m not sure if it’d be as effective as getting a custom wraparound jaw implant + possibly jaw fillers. I figure a custom chin implant can give me the chin height and chin squareness as in the morph and then jaw fillers can give me the jaw angularity and sharpness as in the morph. Hence I was thinking of this other option. But I’m not sure.
 

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if you wanna save some money, you could also just beardmaxx to make your lower third look larger.
 

Surgerymax

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Rather than get a custom wraparound jaw implant + possibly jaw fillers, can I instead maybe opt for a custom chin implant + jaw fillers in order to go for the look I’m aiming for here? This option would be cheaper but I’m not sure if it’d be as effective as getting a custom wraparound jaw implant + possibly jaw fillers. I figure a custom chin implant can give me the chin height and chin squareness as in the morph and then jaw fillers can give me the jaw angularity and sharpness as in the morph. Hence I was thinking of this other option. But I’m not sure.
Here are some other pics of me:
Yes that is a possibility, but I don't think fillers are good for structural augmentation for a number of reasons. They are less predictable, much higer risk of asymmetry and more expensive in the long run.
 

ArabIncel

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Yes that is a possibility, but I don't think fillers are good for structural augmentation for a number of reasons. They are less predictable, much higer risk of asymmetry and more expensive in the long run.
I see. I already have some jaw asymmetry as you’d notice in the pics above. Given that, I suppose it’s probably best I opt for a custom wraparound jaw implant? Now if you look back to the morph again, the body of the mandible stayed the same (or slightly reduced) in the after compared to the before (the gonions in the after sit in the same spot leveled with the mouth or in fact sit slightly higher up as compared to the before). That means that before the implant is placed in, the surgeon will have to shave off vertical height from my ramus, I take it? So he’ll have to perform some kind of ramus reduction “osteotomy” let’s call it, followed by a custom wraparound jaw implant? I had two more questions:

1. How much chin height can the custom wraparound jaw implant add? Comparing my before to my after, it seems at least 12mm of height was added (maybe even more). I’m not sure what the limit is.

2. I take it that perhaps even after this (that is, after the custom wraparound jaw implant) I may not get quite the angularity and sharpness as in the morph. Does that mean after my custom wraparound jaw implant I’ll have to get jaw fillers to close in the gaps? And how safe are jaw fillers over top of a custom wraparound jaw implant in the long run? I hear there’s always a risk of infection when fillers are performed over top of implants.

Thanks.
 

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I have sat down and looked at your pictures in detail. I believe we have talked before about eye area concerns.

You have a vertically short chin from the anterior view likely because of flat occlusal plane. You have a lowset jaw angle and high gonial angle measurement of around 105º. You have an nice hyoid bone position and mandibular plane length. I cannot remember if you sent me pictures of your bite in the past.


I see. I already have some jaw asymmetry as you’d notice in the pics above. Given that, I suppose it’s probably best I opt for a custom wraparound jaw implant?

If that bothers you yes. And for other reasons as well, yes to custom implants.You have a normal degree of asymmetry. It is not true that symettry is the key to beauty - a normal degree of asymettry is considered beautiful. Studys have shown that people find natural (subtle) degrees of asymmetry more attractive than computer optimized symmetric faces.

Now if you look back to the morph again, the body of the mandible stayed the same (or slightly reduced) in the after compared to the before (the gonions in the after sit in the same spot leveled with the mouth or in fact sit slightly higher up as compared to the before). That means that before the implant is placed in, the surgeon will have to shave off vertical height from my ramus, I take it? So he’ll have to perform some kind of ramus reduction “osteotomy” let’s call it, followed by a custom wraparound jaw implant?

Really there are two directions this can go and the first logical thing to do is to consider what implants (and genioplasty) can do without doing these jaw angle reduction osteotomies. Is as close to this morph as possible really necessary? I think you might be happy with certain jaw angle implant designs that still give your face angularity but are not this exact look without you undergoing extra surgery.

If you would like a steeper gonial angle then yes a jaw angle reduction osteotomy can be done. To me, placing an implant at the time of a bone reduction (that is taking cortical bone and leaving a canellous layer and placing an implant on top of it - different than an osteotomy where bone is moved but not removed) is dicey. A subcondylar osteotomy (Horizontal Ramus Osteotomy) is probably not worth it either.

A bimaxillary clockwise rotation of your fat occlusal plane is also an option but is an orthographic tier-approach. It would help the chin seem somewhat less short in itself but not enough to avoid genioplasty or vertical chin implant.

I had two more questions:

1. How much chin height can the custom wraparound jaw implant add? Comparing my before to my after, it seems at least 12mm of height was added (maybe even more). I’m not sure what the limit is.


It is hard to draw the line at any certain millimeter but high implant loads have been associated with an increased complication rate. Looking at your situation in detail I actually recommend a genioplasty with custom jaw extended angle implants.

2. I take it that perhaps even after this (that is, after the custom wraparound jaw implant) I may not get quite the angularity and sharpness as in the morph. Does that mean after my custom wraparound jaw implant I’ll have to get jaw fillers to close in the gaps? And how safe are jaw fillers over top of a custom wraparound jaw implant in the long run? I hear there’s always a risk of infection when fillers are performed over top of implants.


Designed correctly I do not think you will need any filler. If you choose to use filler you are making a non existent risk of latent infection a very small risk. Many experienced facial implant surgeons agree latent infections don't really happen (rare as rare can be). The infection was actually always there since surgery but kept at bay by the immune system or post-operative abx. One exception is mid facial & brow ridge implants where screw fixation is used and the screw enters the maxillary/frontal sinus respectfully. This contact with the sinus (which room air enters) could allow a direct pathway for bacterial inoculation of the implant pocket and thus infection. Your question about injection of fillers poses the same exact kind of risk - that bacteria on the skin (skin can be disinfected but can never be sterilized) enter the implant pocket on the injection needle or cannula.

However, if you otherwise have no route to the outside, the implant pocket heals as a closed space that has no contact or chance for new infection (in most cases)

Thanks.

 

ArabIncel

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I have sat down and looked at your pictures in detail. I believe we have talked before about eye area concerns.

You have a vertically short chin from the anterior view likely because of flat occlusal plane. You have a lowset jaw angle and high gonial angle measurement of around 105º. You have an nice hyoid bone position and mandibular plane length. I cannot remember if you sent me pictures of your bite in the past.


I see. I already have some jaw asymmetry as you’d notice in the pics above. Given that, I suppose it’s probably best I opt for a custom wraparound jaw implant?

If that bothers you yes. And for other reasons as well, yes to custom implants.You have a normal degree of asymmetry. It is not true that symettry is the key to beauty - a normal degree of asymettry is considered beautiful. Studys have shown that people find natural (subtle) degrees of asymmetry more attractive than computer optimized symmetric faces.

Now if you look back to the morph again, the body of the mandible stayed the same (or slightly reduced) in the after compared to the before (the gonions in the after sit in the same spot leveled with the mouth or in fact sit slightly higher up as compared to the before). That means that before the implant is placed in, the surgeon will have to shave off vertical height from my ramus, I take it? So he’ll have to perform some kind of ramus reduction “osteotomy” let’s call it, followed by a custom wraparound jaw implant?

Really there are two directions this can go and the first logical thing to do is to consider what implants (and genioplasty) can do without doing these jaw angle reduction osteotomies. Is as close to this morph as possible really necessary? I think you might be happy with certain jaw angle implant designs that still give your face angularity but are not this exact look without you undergoing extra surgery.

If you would like a steeper gonial angle then yes a jaw angle reduction osteotomy can be done. To me, placing an implant at the time of a bone reduction (that is taking cortical bone and leaving a canellous layer and placing an implant on top of it - different than an osteotomy where bone is moved but not removed) is dicey. A subcondylar osteotomy (Horizontal Ramus Osteotomy) is probably not worth it either.

A bimaxillary clockwise rotation of your fat occlusal plane is also an option but is an orthographic tier-approach. It would help the chin seem somewhat less short in itself but not enough to avoid genioplasty or vertical chin implant.

I had two more questions:

1. How much chin height can the custom wraparound jaw implant add? Comparing my before to my after, it seems at least 12mm of height was added (maybe even more). I’m not sure what the limit is.


It is hard to draw the line at any certain millimeter but high implant loads have been associated with an increased complication rate. Looking at your situation in detail I actually recommend a genioplasty with custom jaw extended angle implants.

2. I take it that perhaps even after this (that is, after the custom wraparound jaw implant) I may not get quite the angularity and sharpness as in the morph. Does that mean after my custom wraparound jaw implant I’ll have to get jaw fillers to close in the gaps? And how safe are jaw fillers over top of a custom wraparound jaw implant in the long run? I hear there’s always a risk of infection when fillers are performed over top of implants.

Designed correctly I do not think you will need any filler. If you choose to use filler you are making a non existent risk of latent infection a very small risk. Many experienced facial implant surgeons agree latent infections don't really happen (rare as rare can be). The infection was actually always there since surgery but kept at bay by the immune system or post-operative abx. One exception is mid facial & brow ridge implants where screw fixation is used and the screw enters the maxillary/frontal sinus respectfully. This contact with the sinus (which room air enters) could allow a direct pathway for bacterial inoculation of the implant pocket and thus infection. Your question about injection of fillers poses the same exact kind of risk - that bacteria on the skin (skin can be disinfected but can never be sterilized) enter the implant pocket on the injection needle or cannula.

However, if you otherwise have no route to the outside, the implant pocket heals as a closed space that has no contact or chance for new infection (in most cases)

Thanks.
Much thanks for the very detailed reply. A few comments and follow-up questions I had:

1. I see that you recommended I get a genioplasty with custom jaw angle implants rather than a single custom wraparound jaw implant that covers both the chin and the jaw angles in order to achieve my goals. This is something I have considered myself in the past. However the reason I parted ways with this option is because I’ve heard a genioplasty risks make asymmetry worse (whereas implants fix it). As you’ll note by the pictures of me above, there is some asymmetry in my chin as well. Another reason I parted ways with this option is because this (that is, a genioplasty) wouldn’t give me the sort of “square” chin which you can see in my morph (whereas an implant can). But now, in favor of a genio, it can probably give the largest amount of downward/vertical projection as opposed to an implant (and as you can see in my morph I do desire a significant amount of downward/vertical projection, 12mm+).

2. Wrt the “reduction” osteotomies that I may need if I really want to achieve my morph (where the gonions sit slightly higher up/ramus is slightly shorter), I’ve heard these can be unsafe and tricky. For instance here is what someone said to me when I asked them about this (in their own words): “You certainly don't want to mess with something like reducing the Ramus, ESPECIALLY since doing so would require a complete release of the pterygomasseteric sling in order to access the inferior border of the angles, and would likely leave you with some degree of permanent masseter muscle retraction as they rarely reattach properly at the inferior border once surgically detached.”

3. Another (general) concern I had was: I’ve heard from various people that custom wraparound jaw implants (and even custom chin implants and custom jaw angle implants) tend to produce lackluster results in those with thicker skin. As you may have noted by my pictures above, I do have thick skin. Not sure how much of a limitation that creates for me in achieving my goals (i.e., the morph).

4. On a separate note, I have attached some pictures of my bite below as well. Not sure if this may be a limitation factor or not.

Thank you.
 

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Surgerymax

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Much thanks for the very detailed reply. A few comments and follow-up questions I had:

1. I see that you recommended I get a genioplasty with custom jaw angle implants rather than a single custom wraparound jaw implant that covers both the chin and the jaw angles in order to achieve my goals. This is something I have considered myself in the past. However the reason I parted ways with this option is because I’ve heard a genioplasty risks make asymmetry worse (whereas implants fix it). As you’ll note by the pictures of me above, there is some asymmetry in my chin as well. Another reason I parted ways with this option is because this (that is, a genioplasty) wouldn’t give me the sort of “square” chin which you can see in my morph (whereas an implant can). But now, in favor of a genio, it can probably give the largest amount of downward/vertical projection as opposed to an implant (and as you can see in my morph I do desire a significant amount of downward/vertical projection, 12mm+).

For that much augmentation, yes, I have to recommend either a genioplasty or combination genioplasty + custom implant at a later date. Look, you could do just an implant and it might look okay from most angles - 15mm vertical augmentations have been done before but they wont feel natural and if you closely you will see the unnatural stepoff from the back of the chin. This has to do with the muscles that are connected to the back of the mandible behind the chin.

If willing to invest the extra money and time for the best result that gets you closest to your ultimate goal once and for all - I recommend the genio+custom implant at a later date approach. The custom implant will fill any contour irregularities from the genio and address any extra assymetry. It will also help to fine-tune the augmentation (you can add a few more mm's naturally wherever you want it, in whatever shape you want it) if the genio only gets you 80% closer to what you want the custom chin implant will be able to take you all the way. You would not need to go to the OR under general for this second part of the staged plan if you dont want to - a chin implant can be quickly and confortably placed under nerve block as an outpatient procedure.


2. Wrt the “reduction” osteotomies that I may need if I really want to achieve my morph (where the gonions sit slightly higher up/ramus is slightly shorter), I’ve heard these can be unsafe and tricky. For instance here is what someone said to me when I asked them about this (in their own words): “You certainly don't want to mess with something like reducing the Ramus, ESPECIALLY since doing so would require a complete release of the pterygomasseteric sling in order to access the inferior border of the angles, and would likely leave you with some degree of permanent masseter muscle retraction as they rarely reattach properly at the inferior border once surgically detached.”


Yes this is a risk but it is overstated and completely out of context. For example, any jaw angle implant which offers vertical augmentation (most of them do to some degree) or have registration tabs (basically all of them are designed to have these) require subperiosteal elevation including underneath the pterygomasseteric sling off the bone. This is not the same as severing the sling (which is an accident or complication that causes masseter muscle dehincence. It is not true that they "rarely re-attatch properly" either.

3. Another (general) concern I had was: I’ve heard from various people that custom wraparound jaw implants (and even custom chin implants and custom jaw angle implants) tend to produce lackluster results in those with thicker skin. As you may have noted by my pictures above, I do have thick skin. Not sure how much of a limitation that creates for me in achieving my goals (i.e., the morph).


Well there are two options that don't require resorting to filler - 1 is to address you facial adiposity. I have a link to my article about managing that in my signature. The other option it to design these a little sharper to overcome your thicker skin.

4. On a separate note, I have attached some pictures of my bite below as well. Not sure if this may be a limitation factor or not.


They are not. I wanted to see because the highest tier plan would involve a BSSO Clockwise Rotation of your occlusal plane but I don't think you want that.

Thank you.
 

ArabIncel

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Much thanks for the very detailed reply. A few comments and follow-up questions I had:

1. I see that you recommended I get a genioplasty with custom jaw angle implants rather than a single custom wraparound jaw implant that covers both the chin and the jaw angles in order to achieve my goals. This is something I have considered myself in the past. However the reason I parted ways with this option is because I’ve heard a genioplasty risks make asymmetry worse (whereas implants fix it). As you’ll note by the pictures of me above, there is some asymmetry in my chin as well. Another reason I parted ways with this option is because this (that is, a genioplasty) wouldn’t give me the sort of “square” chin which you can see in my morph (whereas an implant can). But now, in favor of a genio, it can probably give the largest amount of downward/vertical projection as opposed to an implant (and as you can see in my morph I do desire a significant amount of downward/vertical projection, 12mm+).

For that much augmentation, yes, I have to recommend either a genioplasty or combination genioplasty + custom implant at a later date. Look, you could do just an implant and it might look okay from most angles - 15mm vertical augmentations have been done before but they wont feel natural and if you closely you will see the unnatural stepoff from the back of the chin. This has to do with the muscles that are connected to the back of the mandible behind the chin.

If willing to invest the extra money and time for the best result that gets you closest to your ultimate goal once and for all - I recommend the genio+custom implant at a later date approach. The custom implant will fill any contour irregularities from the genio and address any extra assymetry. It will also help to fine-tune the augmentation (you can add a few more mm's naturally wherever you want it, in whatever shape you want it) if the genio only gets you 80% closer to what you want the custom chin implant will be able to take you all the way. You would not need to go to the OR under general for this second part of the staged plan if you dont want to - a chin implant can be quickly and confortably placed under nerve block as an outpatient procedure.


2. Wrt the “reduction” osteotomies that I may need if I really want to achieve my morph (where the gonions sit slightly higher up/ramus is slightly shorter), I’ve heard these can be unsafe and tricky. For instance here is what someone said to me when I asked them about this (in their own words): “You certainly don't want to mess with something like reducing the Ramus, ESPECIALLY since doing so would require a complete release of the pterygomasseteric sling in order to access the inferior border of the angles, and would likely leave you with some degree of permanent masseter muscle retraction as they rarely reattach properly at the inferior border once surgically detached.”

Yes this is a risk but it is overstated and completely out of context. For example, any jaw angle implant which offers vertical augmentation (most of them do to some degree) or have registration tabs (basically all of them are designed to have these) require subperiosteal elevation including underneath the pterygomasseteric sling off the bone. This is not the same as severing the sling (which is an accident or complication that causes masseter muscle dehincence. It is not true that they "rarely re-attatch properly" either.

3. Another (general) concern I had was: I’ve heard from various people that custom wraparound jaw implants (and even custom chin implants and custom jaw angle implants) tend to produce lackluster results in those with thicker skin. As you may have noted by my pictures above, I do have thick skin. Not sure how much of a limitation that creates for me in achieving my goals (i.e., the morph).

Well there are two options that don't require resorting to filler - 1 is to address you facial adiposity. I have a link to my article about managing that in my signature. The other option it to design these a little sharper to overcome your thicker skin.

4. On a separate note, I have attached some pictures of my bite below as well. Not sure if this may be a limitation factor or not.

They are not. I wanted to see because the highest tier plan would involve a BSSO Clockwise Rotation of your occlusal plane but I don't think you want that.

Thank you.
thanks for the answers. So from what I gather and correct me if I’m wrong, my best option is this:

1. To get a genioplasty in order to vertically augment the lower jaw/chin to some extent.

2. To then get a custom chin implant in order to further vertically augment the lower jaw/chin (just enough more to meet the morph) and to make the chin slightly wider if need be and more square (as per the morph).

3. To then get either custom jaw angle implants OR jaw fillers in order to make the jaw more angular and sharp.

And possibly in between (2) and (3) I may need some kind of ramus reduction osteotomy of sorts to raise the gonions from frontal perspective.

So this would all be a three or four step process.