jawsurgeryforums.com
General Category => Aesthetics => Topic started by: The Quest for Aesthetics on February 12, 2017, 07:26:01 AM
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Am I right in saying that the principle advantage of SARPE over segmental le fort 1 for maxillary widening is the amount of widening obtainable? Do either of these procedures differ in the quantity of maxilla (vertically speaking) that can potentially be mobilised for this widening? Essentially I'm looking to broaden as much of the midface as possible, which extends beyond the dentoalveolar part of the maxilla.
Any comments/knowledge will be appreciated
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Asked around and the answer is no for adults, yes in those still growing
I was also hoping to broaden my upper midface
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Am I right in saying that the principle advantage of SARPE over segmental le fort 1 for maxillary widening is the amount of widening obtainable? Do either of these procedures differ in the quantity of maxilla (vertically speaking) that can potentially be mobilised for this widening? Essentially I'm looking to broaden as much of the midface as possible, which extends beyond the dentoalveolar part of the maxilla.
Any comments/knowledge will be appreciated
you can do it --SARPE ---that is, segmental won't make any difference in looks
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you can do it --SARPE ---that is, segmental won't make any difference in looks
Why is this? Is it purely because just not enough widening can be achieved with it?
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Asked around and the answer is no for adults, yes in those still growing
I was also hoping to broaden my upper midface
Sorry could you expand on that please?
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Am I right in saying that the principle advantage of SARPE over segmental le fort 1 for maxillary widening is the amount of widening obtainable? Do either of these procedures differ in the quantity of maxilla (vertically speaking) that can potentially be mobilised for this widening? Essentially I'm looking to broaden as much of the midface as possible, which extends beyond the dentoalveolar part of the maxilla.
Any comments/knowledge will be appreciated
My understanding is that SARPE uses the some type of bone incision as a single segment Lefort. Dr. Gunson told me that he could achieve any expansion he wanted to multi-segment Lefort and mentioned "centimeter." I don't have the impression he ever thinks SARPE is preferable - I could be wrong about that.
I don't see why a four segment Lefort cannot achieve good posterior and anterior expansion.
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My understanding is that SARPE uses the some type of bone incision as a single segment Lefort. Dr. Gunson told me that he could achieve any expansion he wanted to multi-segment Lefort and mentioned "centimeter." I don't have the impression he ever thinks SARPE is preferable - I could be wrong about that.
I don't see why a four segment Lefort cannot achieve good posterior and anterior expansion.
Now this is interesting. I'm going to see dr Gunson in June so I will mention this. @Lazlo would you be able to add anything here?
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Now this is interesting. I'm going to see dr Gunson in June so I will mention this. @Lazlo would you be able to add anything here?
I was very focused on this question of SARPE vs. multi-segment Lefort. Initially, I was pretty convinced that SARPE would be required to to get the anterior expansion that I wanted, including reducing the conical shape of the arch form. I now think that a four-piece Lefort can likely do what I want it to do, which includes having more lateral tooth show, and minimal buccal corridors. I'm scheduled with Dr. Gunson later this year.
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Sorry could you expand on that please?
Sorry I meant it would only affect the dentoalveolar level in adults!
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These surgeries expend the arch and nothing else. And it has to match the lower one - so only done when the lower is wider.
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These surgeries expend the arch and nothing else. And it has to match the lower one - so only done when the lower is wider.
Are we sure that these are true parameters, or rather that this is the way the procedure is almost exclusively carried out?
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I had my maxilla brought forward 9 mm, down 5mm and widened 4mm with le fort 1.
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I had my maxilla brought forward 9 mm, down 5mm and widened 4mm with le fort 1.
Did your surgeon mention anything more about the widening? For instance did he imply that more was possible?
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Gunson said he can widen 1cm????
So as you know how much you can widen maxilla is dependent on how wide your mandible is (which only like Dr. Li actually practices expanding). I've heard the upper limit of independent multi-seg lefort 1 is 7mm and it usually relapses 4mm so you only get like 3-4mm. I don't feel much if any wider after my lefort.
1cm you would feel. It would probably be AMAZING. But I've only heard SARPE can do that. Oh and it would DEFINITELY make your cheekbones wider since they're connected to the maxillary bone/complex. If you can get 1cm from gunson do it.
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Gunson said he can widen 1cm????
So as you know how much you can widen maxilla is dependent on how wide your mandible is (which only like Dr. Li actually practices expanding). I've heard the upper limit of independent multi-seg lefort 1 is 7mm and it usually relapses 4mm so you only get like 3-4mm. I don't feel much if any wider after my lefort.
1cm you would feel. It would probably be AMAZING. But I've only heard SARPE can do that. Oh and it would DEFINITELY make your cheekbones wider since they're connected to the maxillary bone/complex. If you can get 1cm from gunson do it.
Lazlo how can we be certain that the zygoma will move outward with the mobilise maxillary segment? I mean the zygoma' attached to other parts of the midface that aren't mobilised so surely it's a bit far fetched to suppose that it would move in that way?
I will enquire about the multi segmental le fort with Gunson. I wonder no surgeon mobilises the lower palate? I'm assuming it's because the cut would be in a completely different place on the mandible to a standard BSSO, but why aren't surgeons comfortable making two separate cuts?
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My impression is that SARPE is a cut while LeFort is a downgraft. Where they add bone is different as well as how - one is a distraction process and the other is a healing process. The type of bone that fills in may be different as well. Relapse is probably dependent on surgical technique. Segmental LeFort is often grafted for stability but I don't love it because those grafts aren't real bone while a SARPE at least produces that. I've also read that SARPE can produce much greater movements than segmental LeFort, which is indicated for ~3mm-7mm. What can be accomplished has to be taken in context of the overall surgical plan since there are risks unique to a segmental LeFort. SARPE is done as a separate surgery which is part of the reason surgeons like to avoid it but it is also thought to be safer. Segmental LeFort can also produce vertical movements that SARPE cannot but then segmental LeFort turns your maxilla into an imperfect jigsaw puzzle that the surgeon compensates for with grafts and recontouring. In both cases the osteotomy is below the zygoma and will have no impact on it. I think segmental LeFort has become somewhat safer with newer tools and technique but it's still inherently riskier, even if the risks are small.
Basically it comes down to surgeon preference which route to take and part of that decision is what standards the surgeon will be held to.
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What about two piece lefort?
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My impression is that SARPE is a cut while LeFort is a downgraft. Where they add bone is different as well as how - one is a distraction process and the other is a healing process. The type of bone that fills in may be different as well. Relapse is probably dependent on surgical technique. Segmental LeFort is often grafted for stability but I don't love it because those grafts aren't real bone while a SARPE at least produces that. I've also read that SARPE can produce much greater movements than segmental LeFort, which is indicated for ~3mm-7mm. What can be accomplished has to be taken in context of the overall surgical plan since there are risks unique to a segmental LeFort. SARPE is done as a separate surgery which is part of the reason surgeons like to avoid it but it is also thought to be safer. Segmental LeFort can also produce vertical movements that SARPE cannot but then segmental LeFort turns your maxilla into an imperfect jigsaw puzzle that the surgeon compensates for with grafts and recontouring. In both cases the osteotomy is below the zygoma and will have no impact on it. I think segmental LeFort has become somewhat safer with newer tools and technique but it's still inherently riskier, even if the risks are small.
Basically it comes down to surgeon preference which route to take and part of that decision is what standards the surgeon will be held to.
Thanks, great post. On a related point do you know of any procedure aimed at widening the central maxilla (think around the piriform aperture)? I mean from seeing before and afters of lower maxillary expansion the issue is that one part of the midface is out of sync with the remainder of the midface in terms of breadth.
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I see that relapse is mentioned quite a bit so maybe I should worry more than I do about relapse. I had my BSSO and multi segment lefort 1 done in August 2015 and I honestly don't seem to have any relapse. When I smile I still see the same amount of upper gum and my retainers still fit fine with no bite changes. My previous adventure with braces had my upper molars flared out to mesh with my lower. This time around with surgery and braces, my maxilla was split and widened having my upper mesh ??? properly with the bottom. Nothing has changed after the surgery. How long should final stability be achieved?
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You should be fine after 1 year.
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SARPE has a number of subtle effects which aren't apparent on immediate observation:
- Minor clockwise rotation of the maxilla
- Short term increase in facial convexity
- But long term anterior facial height is unchanged
- Nice side effect is the zygoma are laterally and superiorly moved
There are some obvious changes to nasal structure as well.
Due to the stresses this places on the zygoma and zygomatic arch I'm inclined to think I should get this done before my LF3.
Interesting, do you know how that affect compares to a ZSO?
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I saw SARPE results at Dr. Z office, was quite impressed particularly with respect to mouth area improvement. But it wasn't standalone SARPE.
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I saw SARPE results at Dr. Z office, was quite impressed particularly with respect to mouth area improvement. But it wasn't standalone SARPE.
What improvements did you note in particular and did you enquire as to the other procedures performed alongside SARPE?
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I had SARPE 5 months ago. The relapse have been huge, i've lost more then 50% of my expansion, even though there is a device installed on my palate to keep the jaw stable. I honestly believe i'll relapse even more, because i can feel a substantial pressure around the created gap. Two orthodontists later on told me expansion of the palate in adults is basically the most unstable osteotomy there is.
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Any further thoughts on this subject?
From my research, multipiece LF1 traditionally maxes out below 1 cm. Anything 1 cm or more requires SARPE. I haven't talked to Gunson about this though to see his opinion. Has anyone asked him?
SARPE can relapse in part because a lot of the expansion can actually be dental (not from bone). I need 8 mm expansion and Caminiti said he wanted to do SARPE out to 1.1 or 1.2 cm to ensure we have enough expansion even after some anticipated relapse. It needs to be overexpanded to plan for this.
He said a multipiece LF1 would not be viable for me as if we did it for 8-9 mm, the relapse would bring us down to 6 mm or so and then I'm still in crossbite.
I am confused about the widening midface/zygos effect people are claiming from SARPE.
How is a SARPE performed? Are there multiple techniques?
I see this diagram which shows a split just down the middle. This would definitely widen the cheekbones/midface in a favorable way:
(http://www.toportho.org/uploads/7/0/1/1/70110125/6658111.jpg)
However, I was always under the impression THIS is how SARPE works:
(https://d2kw0licpa1moo.cloudfront.net/9664833_1502174305.8087_updates.jpg)
This approach will not in any way widen the cheekbones as you are just basically doing a multipiece LF1 gradually over time. The surgical approach is summarized here, using a bone borne expander:
https://www2.aofoundation.org/wps/portal/surgerymobile?contentUrl=/srg/95b/05-RedFix/P370-SurgAssRapPalExp/05_Expansion.jsp&soloState=precomp&title=&Language=en
This article seems quite thorough on the subject but I'm still not understanding how it can or can't affect the zygos.
http://www.toportho.org/think-pieces/sarpe-a-frequently-misunderstood-surgical-procedure
From what I understand reading it, the technique implemented in the green CT scan above where the whole midface is widened is the OLD way of doing it that no one does anymore, because it's highly risky and has led to terrible complications when the entire skull fractures from the strain. They say a SARPE is basically exactly the same as a multipiece LF1 in the cuts, except the "down fracture" is more complete in a multipiece LF1. That's it.
So I don't think modern SARPE should provide any benefit to the zygos at all.
The quote most relevant to me is:
Myth: SARPE is needed as the first phase of surgical technique when skeletal transverse and a-p / vertical change are desired.
Why would you do that? In theory, so that in a second surgical phase the maxilla can be repositioned in one piece and the transverse expansion will be more stable.
The problem with that concept is that results with one-phase segmental osteotomy for transverse changes and a-p / vertical repositioning at the same time are remarkably similar to the results with two-phase surgery. At present, there is a divide between surgeons in the northeastern US and eastern Canada, many of whom advocate two-phase treatment for three-dimensional problems, and those in the rest of the US and Canada, who usually manage problems in all three dimensions with a single surgery. The two-phase treatment has greater morbidity, cost, and difficulty in a repeat of the bone cuts that were done in the first procedure. It is hard to justify that if you can get the same results with a single surgery, and orthodontists should be sensitive to this point (3,4).
The bottom line: at present, SARPE offers a slight advantage to the patient in stability and surgical morbidity when only transverse changes from maxillary surgery are needed, and a significant disadvantage when three-dimensional changes are needed. It is indicated only when transverse expansion is all the patient needs.
So maybe I don't need a SARPE at all. I just need someone capable of juggling 2-3 fragments simultaneously and getting it all done at once.
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This is an excellent presentation on the subject of SARPE vs. segmental LF1.
https://www.slideshare.net/sylvainchamberland/sarpe-2-stages-vs-le-fort-1-single-stage-approach-to-complex-maxillary-deformities-a-critical-review-and-update
Here are the most important slides:
(https://s17.postimg.org/5o81g9rr3/image.png)
(https://s17.postimg.org/mbzjiru8f/image.png)
(https://s17.postimg.org/85jsnjr33/image.png)
(https://s17.postimg.org/flj29cmi7/image.png)
So I am very curious what guys like Wolford and Gunson do with big transverse deficiencies if they "don't do SARPE".
As nice as a single stage procedure would be, it seems those of us with big deficiencies are just f**ked with needing SARPE.
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Here's another article specifying a limit of 5-7 mm for segmental lefort 1 and that higher poses unacceptable vascular risks:
"The limit for expansion is about 5 to 7 mm, without imposing vascular risks to the palatal mucosa."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4327542/
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It is safe to have a segmental Lefort 1 + upper jaw extrusion at the same time ?
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It is safe to have a segmental Lefort 1 + upper jaw extrusion at the same time ?
Upper jaw 'extrusion' = Vertical lengthening upper jaw.
I don't know how safe enough it is. But it is something that is done where there is a transverse deficiency (maxillae needing to be 'spread out' more 'horizontally') and also when vertical 'drops' are needed to the segments.