Facial Surgery

Masseter Muscle Reattachment After

Mandibular Angle Surgery
Mathew A. Thomas, MD; and Michael J. Yaremchuk, MD

Background: Altering the dimensions of the mandibular angle by alloplastic augmentation or skeletal reduc-
tion requires elevation of the insertion of the masseter muscle, including the pterygomasseteric sling.
Disruption of the pterygomasseteric sling during exposure of the inferior border of the mandible can cause
the masseter muscle to retract superiorly, resulting in a loss of soft tissue volume over the angle of the
mandible and a skeletonized appearance. Subsequent contraction of the masseter elevates the disinserted
edge of the muscle and not only increases the skeletonized area, but also exaggerates the deficiency by caus-
ing a soft tissue bulge above it.
Objective: The authors describe the disinsertion of the masseter and the resulting deformity as a potential
complication of mandibular angle surgery and review the technique for repair.
Methods: The records of 60 patients (44 primary, 16 secondary) who presented for alloplastic mandible
augmentation between 2003 and 2008 were reviewed.
Results: Nine patients presented with clinical signs of disruption of the pterygomasseteric sling after mandibular
angle surgery. Five patients had clinical signs consistent with complete disruption. Two of these patients requested
reconstruction. The other four had signs consistent with partial disruption. Through a Risdon approach, the mas-
seter was successfully reinserted using drill holes placed at the inferior border of the mandible.
Conclusions: Masseter disinsertion is a previously unreported sequelae after aesthetic surgery for the angle
of the mandible. The resultant static and dynamic contour deformity can be corrected by reattaching the mus-
cle to the inferior border of the mandible. (Aesthet Surg J; 29:473-476.)

A
esthetic surgery of the mandibular angle includes
both augmentation and reduction of the bony struc-
ture. Alloplastic augmentation can be performed to
accentuate the definition of the lower jawline or to compen-
sate for mandibular deficiency.1-8 Surgical reduction has
also been described for the treatment of prominent
mandibular angles, particularly in Asian societies.9
Unwanted outcomes from these procedures usually result
from asymmetries, undercorrections, or overcorrections.
Both of these procedures (augmentation and reduction)
require subperiosteal exposure of the skeleton with con-
comitant elevation of the masseter muscle insertion and
the pterygomasseteric sling (PS). This exposure may dis-
rupt the PS and cause the masseter muscle to retract
superiorly, causing a loss of soft tissue volume over the
mandibular angle and a skeletonized appearance.
SURGICAL ANATOMY
The masseter muscle originates from the inferior border
and medial surface of the zygomatic arch and inserts
Dr. Thomas is a resident in plastic surgery and Dr. Yaremchuk is
the Director of Craniofacial Surgery in the Division of Plastic
Surgery, Department of Surgery, Massachusetts General Hospital
and Harvard Medical School, Boston, MA.
broadly onto the lateral surface of the ramus of the
mandible and the coronoid process. The medial ptery-
goid originates from the region of the lateral pterygoid
plate and inserts onto the medial surface of the ramus10
(Figure 1, A). At the inferior border of the mandible,
both the masseter and medial pterygoid muscles have
strong tendinous insertions that adhere in proximity to
the periosteum and, as a group, are often referred to as
the PS. Again, disruption of the sling (Figure 1, B) can
result in a loss of soft tissue. Subsequent contraction of
the masseter elevates the disinserted edge of the muscle
and not only increases the skeletonized area, but also
exaggerates the deficiency by causing a soft tissue bulge
above it (Figure 1, C).
The PS and masseter insertion can be intentionally or
unintentionally disrupted in a variety of surgical proce-
dures that require exposure of the inferior border and
angle of the mandible. By necessity, an extraoral
approach to the angle of the mandible always requires
the division of the PS.3 However, disruption of the sling
can also occur through an intraoral approach. Standard
intraoral techniques for exposure of the mandible use a
variety of instruments that have been developed to facili-
tate the retraction and release of the masseter to gain

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 A B C
Figure 1. An illustration of the pterygomasseteric sling (PS) and the effects after its disruption. A, At the inferior border of the mandible, both the
masseter and medial pterygoid muscles have strong tendinous insertions that form the PS. B, The PS has been disrupted during exposure of the
inferior border of the mandible for placement of a mandibular angle implant. C, Contraction of the masseter elevates the disinserted edge of the
muscle, resulting in a skeletonized area over the implant and a soft tissue bulge above it.

A B C
Figure 2. Intraoperative masseter reattachment. A, Through a Risdon incision just below the angle of the mandible, the edge of the masseter has
been identified. Sutures have been placed through the inferior edge of the muscle and through drill holes in the inferior border of the mandible.
B, The sutures have been tied down, bringing the masseter into a more anatomic position. C, A piece of Enduragen (porcine dermal collagen;
Porex Surgical, Newnan, GA) has been sutured over the repair to ensure a smooth contour.

surgical exposure to the inferior border of the mandible
(including the Bauer retractor, the LeVasseur-Merrill
retractor, and J-strippers).11 During split ramus osteotomy
for mandibular advancement in orthognathic surgery, the
exposure carried out along the buccal side of the
mandible requires detachment of at least a portion
of the masseter muscle.12 Elevation (but not disrup-
tion) of the PS has also been described in the subpe-
riosteal placement of mandibular angle implants through
an intraoral incision.1,3,5,6,13 Elevation of the PS is also
necessary to expose the angle of the mandible for reduc-
tion surgery.9 Intentional incision of the PS has even
been described as a means of increasing the vertical
height of the posterior mandible.14
REATTACHMENT OF THE MASSETER MUSCLE
Reduction and augmentation of the posterior mandible
are routinely performed from above through an intraoral
sulcus approach. However, because masseter reattach-
ment requires not only exposure of the inferior border of
the mandible, but also mobilization of both the anterior
and posterior surfaces of the masseter muscle, a more
direct access to these structures is required. Therefore,
under general anesthesia, the inferior border of the
mandible is approached through a Risdon incision placed
just below the angle of the mandible (Figure 2, A). The
platysma is divided. Care should be taken to avoid injury
to the marginal branch of the facial nerve or to the facial
artery. After identifying the inferior border of the
mandible, subperiosteal dissection of the anterior surface
of the mandibular ramus is performed. This allows identi-
fication of the posterior surface and, subsequently, the
detached inferior edge of the superiorly retracted masseter
muscle. Drill holes are placed in the inferior border of the
mandible. These are used to reattach the inferior edge of
the masseter muscle with a nonabsorbable suture (Figure
2, B). If a mandibular angle implant is present, the muscle
can be secured to the inferior edge of the implant.
Additional implants may be required as an onlay to
smooth residual contour irregularities (Figure 2, C).

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 Table. Patient characteristics
Patient no. Age, years Sex
1 26
2 30
3 54
4 32
5 35
6 30
7 36
8 38
9 32
No. of previous Partial or
Initial procedure Implant position procedures complete disruption?
M Augmentation Wraparound 2 Partial
M Augmentation Wraparound 2 Partial
M Augmentation Wraparound 2 Complete
M Augmentation Inferior ledge 1 Partial
M Augmentation Wraparound 1 Complete
F Augmentation Onlay 2 Complete*
F Reduction N/A 1 Complete*
F Augmentation Inferior ledge 2 Complete
M Augmentation Onlay 2 Partial

F, female; M, male; N/A, not applicable.

*Underwent surgical repair.

A B
Figure 3. A, Preoperative view of the 30-year-old woman featured in Figure 2, who suffered disruption of the pterygomasseteric sling after unsat-
isfactory placement and subsequent removal of mandibular angle implants. Note the soft tissue deficiency in the region of the mandibular angle.
The patient is pictured with active contraction of the masseter muscle, causing a superior bulge that exaggerates the soft tissue deficiency. B, One
year after masseter reattachment, showing restoration of the contour of the mandibular angle.

Postoperatively, the patient is directed to employ an active
range of jaw motion within 48 hours after surgery and to
avoid forceful chewing for three weeks after surgery.
METHODS
Between 2003 and 2008, 60 patients presented for allo-
plastic mandible angle augmentation. Forty-four
patients underwent primary surgery with the senior
author (MJY). This personal series constitutes 86
angles, with two patients undergoing unilateral surgery.
Two of the patients (2.3%) were noted to have a slight
soft tissue depression and overlying muscle bulge with
forceful contraction of their masseter muscle after
implant surgery. Of note, neither patient was aware of
the subtle deformity. Sixteen additional patients were
referred for revision of previous mandibular angle
implant surgery. Seven of these patients complained of
(and had clinical findings consistent with) masseter
disinsertion. This resulted in a total of nine patients
with this deformity (two primary patients and seven
patients referred for revision). Five of the nine patients
had clinical signs consistent with complete disruption of
the PS. The clinical information associated with these
patients is presented in the Table. Two of the patients
with complete disruption requested surgical repair. The
preoperative, intraoperative, and postoperative images
of one of the patients who underwent masseter reat-
tachment are shown in Figures 2 and 3.
DISCUSSION
Surgery to alter the dimensions of the angle of the
mandible requires elevation of the PS from the inferior
border of the mandible. There have been previous reports
discussing the complications specifically associated with
mandibular angle augmentation or reduction.1,3,4,9,15 The
most common concerns include infection, hematoma,
and asymmetry, although these appear to be relatively
rare. Postoperative trismus is a more likely possibility
when surgery involves resection of the masseter muscle.9
Other reported complications include temporary total
facial nerve palsy, marginal mandibular palsy, mental
nerve palsy, and retromandibular vein rupture.
Despite reports of other complications, neither the
contour deformity that results if the sling has been
disrupted during this exposure nor the surgical correc-
tion of the deformity have been reported. To our
knowledge, the incidence of this problem after
mandible angle surgery is not yet documented. In the
series of 44 patients (86 mandibular angles) undergo-
ing primary mandibular angle augmentation by the
senior author (out of a total of 60 in the full series),
two patients had evidence of partial disruption of

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 their PS noted with forceful contraction of their mas-
seter muscle. The incidence of partial disruption in
this series was 2.3%.
A review of the clinical characteristics of the patients
who presented with signs of damage to the PS provides
a platform to discuss factors that may predispose to this
condition (Table). The results from patients who suf-
fered sling disruption after angle reduction suggest that
sling elevation and retraction alone are sufficient to
result in this deformity. This may reflect poor operative
technique or may be a function of that patient’s particu-
lar anatomy. Most of these patients had more than one
operation performed in the area. Repetitive surgery in
this area, particularly the removal and replacement of
implants, makes damage to the sling more likely. Many
of the implants were designed to completely wrap
around the inferior border of the mandible and therefore
require degloving not only the anterior surface and infe-
rior border of the mandible, but also its posterior aspect.
Placing an implant with this design requires additional
mobilization of the soft tissues, which may thereby
increase the possibility of sling damage. The amount of
vertical and lateral augmentation provided by the
implant will also influence the potential for sling com-
promise.
It is possible that many, if not all, patients who
undergo elevation of the PS have some disruption of its
integrity that is not clinically appreciable. Even some of
the subjects included in this study were unaware of the
deformity. The subtle nature of this postoperative
change is undoubtedly one reason why this sequela has
not been previously documented.
Based on the personal experience of the senior
author,13 we suggest the following practices to avoid PS
disruption during mandible implant surgery:
1. Infiltration of the operative site with epinephrine-
containing solution to maximize hemostasis;
2. Generous intraoral incisions to optimize operative
site exposure and facilitate implant placement;
3. Strict subperiosteal dissection to minimize sling
disruption;
4. Use of implants that provide lateral and vertical
augmentation compatible with the patient’s soft
tissue envelope; and
5. Screw fixation of the implant to prevent implant
movement and lessen the likelihood of revisional
surgery.
CONCLUSIONS
Elevation of the PS is required to expose the inferior bor-
der of the mandible during angle augmentation or reduc-
tion surgery. Disruption of the PS during exposure of the
inferior border of the mandible can cause the masseter
muscle to retract superiorly, with consequent loss of soft
tissue volume over the angle of the mandible and a
skeletonized appearance. This deformity is dynamic with
contraction of the masseter, resulting in not only an
increased area of skeletonization, but also an exaggera-
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tion of the deficiency because of a soft tissue bulge
above it. Damage to the sling may be minimized by its
careful elevation and retraction, the use of appropriately
sized implants, and avoidance of secondary surgery. The
clinical appearance may range from subtle to obvious,
depending on the degree of disruption. This deformity
can be corrected by reattachment of the muscle to the
inferior border of the mandible. ◗
DISCLOSURES
The authors have no disclosures with respect to the contents of this
article.
REFERENCES
1. Ousterhout DK. Mandibular angle augmentation and reduction. Clin
Plast Surg 1991;18:153–161.
2. Yaremchuk MJ. Mandibular augmentation. Plast Reconstr Surg
2000;106:697–706.
3. Semergidis TG, Migliore SA, Sotereanos GC. Alloplastic augmentation of
the mandibular angle. J Oral Maxillofac Surg 1996;54:1417–1423.
4. Terino EO. Unique mandibular implants, including lateral and posterior
angle implants. Facial Plast Surg Clin North Am 1994;2:311–328.
5. Whitaker LA. Aesthetic augmentation of the posterior mandible. Plast
Reconstr Surg 1991;87:268–275.
6. Aiache AE. Mandibular angle implants. Aesthetic Plast Surg
1992;16:349–354.
7. Taylor CO, Teenier TJ. Evaluation and augmentation of the mandibular
angle region. Facial Plast Surg Clin North Am 1994;3:329.
8. Ramirez OM. Mandibular matrix implant system: a method to restore
skeletal support to the lower face. Plast Reconstr Surg
2000;106:176–189.
9. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle: preop-
erative management, operative technique and results in 42 patients.
Plast Reconstr Surg 1989;83:272–280.
10. Moore K, Dalley A. Clinically oriented anatomy, 4th ed. Baltimore:
Lippincott Williams & Wilkins, 1999:921.
11. Ellis E, Zide MF. Surgical approaches to the facial skeleton, 2nd ed.
Philadelphia: Lippincott Williams & Wilkins, 2006:155–161.
12. Reyneke JP. Essentials of orthognathic surgery. Chicago: Quintessence,
2003:248–249.
13. Yaremchuk MJ. Atlas of facial implants. Philadelphia: Saunders
Elsevier, 2007:197–222.
14. Ferri J, Ricard D, Genay A. Posterior vertical deficiencies of the
mandible: presentation of a new corrective technique and retrospective
study of 21 cases. J Oral Maxillofac Surg 2008;66:35–44.
15. Lee Y, Kim JH. Mandibular contouring: a surgical technique for the
asymmetrical lower face. Plast Reconstr Surg 1999;104:1165–1171.
Accepted for publication February 26, 2009.
Reprint requests: Michael J. Yaremchuk, MD, Division of Plastic Surgery,
Department of Surgery, Massachusetts General Hospital, 15 Parkman St.,
Wang 435, Boston, MA 02114. E-mail: dr.y@dryaremchuk.com.
Copyright © 2009 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$36.00
doi:10.1016/j.asj.2009.09.006
Aesthetic Surgery Journal