General Category > Functional Surgery Questions
Surgery Advice lefort I + sliding genioplasty? pics and x-rays included
surgeryadvice:
Hi,
I was treated for an underbite as a kid. Unfortunately, my orthodontist at the time told me that he wasn't able to fully correct the skeletal issues underlying the underbite, namely a retruded and narrow maxilla, narrow mandible, and long midface. He also told me that my issues were likely caused by incorrect tongue posture as a kid (tongue on bottom of mouth) as well as s**tty genetics. This resulted in a lack of anterior projection of the maxilla as well as the narrow palate. I also genetically have a low mandibular plane angle resulting in a short lower face (I've been told that having a low mandibular plane angle + narrow jaws + a long and slightly recessed maxilla is quite rare). As a result of occlusal trauma in the past (likely due to my underbite) I also have some recession near my incisors. I also have a posterior open bite.
In recent years I've started to look for options to correct these issues, both for functional as well as aesthetic reasons. I visited with Dr. Jamali in NYC. He confirmed most of what my old orthodontist told me but he said that the risk of proceeding with the surgeries needed to correct my issues was quite significant. After my visit with Dr. Jamali I went to an orthodontist to ask for his opinion. He confirmed everything my old orthodontist and Dr. Jamali told me. He agreed that correcting my issues would be difficult. He suggested visiting with a facial plastic surgeon who specializes in maxillofacial surgery to ask for his/her opinion. I visited with Dr. Michael Yaremchuk in Boston. He also confirmed that my midface is recessed and that both jaws are narrow and that my LAFH is short. He told me that due to my recessed midface I have what is called a "negative orbital vector", resulting in protrusive eyes and dark hollows under my eyes. According to dr. Yaremchuk my orbital rims are also deficient in every direction. He suggested starting with a sliding genioplasty + chin contouring to address the short LAFH and my bony irregularities on my chin. Next, he suggested orbital rim implants + cheek implants to address the midface and the negative orbital vector. I asked if I should consider a Lefort I surgery to address my recessed jaws, however, he said that aesthetically this would not look good and instead accentuate the negative orbital vector. He told me I should look into jaw implants as well.
I have a few questions.
1. Does a sliding genioplasty to primarily add vertical length result in a step off where the bone was cut (pre-jowl)?
2. I've seen a bunch of before and after for SG. It appears that a lot patients have narrower lips (horizontally and vertically). This is precisely what I don't want to have happen. Is this a known risk?
3. Looking at my ceph, does anybody here have any insight into how recessed my jaws are? I've never gotten an exact answer, just a "yes, your jaws are recessed".
4. What is the recovery like for a Lefort I? Is nerve damage a serious risk?
5. Does anybody have any experience with facial implants? If so, what has your experience been like, good, bad, so so?
Here are my x-rays and pictures.
Ceph https://i.imgur.com/RKlO20X.jpg
Pano https://i.imgur.com/Qlqh1Fy.jpg
Profile, note the flat midface + protruding eyes/negative vector https://i.imgur.com/rAa022x.jpg
Profile smiling https://i.imgur.com/o5f98Kb.jpg
Front, narrow face, narrow jaws, short lower third https://i.imgur.com/Q5qjvEs.jpg
Lazlo:
you don't really have a negative vector.
just get some sun for christsakes and see a derm about the pores on your nose.
and yeah a vertically lengthening and slightly forward genio would help your case a lot. Don't worry abotu lips and all that s**t.
kavan:
I don't see a negative orbital vector. Perhaps a 0 vector but not a 'negative' one. So with ORIS, they would give a positive orbital vector. But I don't see the type of recession or 'prominent eye' that is the 'true' indication for the ORIs. However, IF, for example, you had bi-max surgery to advance both jaws, the Lefort 1 aspect of it would leave the upper midface area (orbital rim/cheek complex) 'behind' by relative comparison.
What you have is basically a horizontal growth pattern to the jaws which means more 'compactness' to the face as opposed to 'length'. But still, the proportions, relative to each other are very good (equal '1/3rds'). I don't see any 'long' midface or relative disproportions to the bone structure.
Although your jaws might be recessed 'absolutely' like in accordance of a norm for your age and sex, it just means you might have a smaller face/head than the norm. But STILL, they look in PROPORTION to each other.
The chin contour from the front is actually great because the horizontal line to center bottom of it is what makes the face look 'angular' where the lines from lateral chin to back of jaw are 'diagonal'. I would not 'exchange' that type of angular frontal contour for a 'U' type contour which sounds like you would get with the BURRING of the chin and drop down just so an implant would better fit.
The only disproportion I see to the face is the NOSE which is too big for the face. So, you would be looking for doctors who could perform reduction rhino, not really to the bone but rather to the 'excess flesh' you have the nose.
surgeryadvice:
--- Quote from: kavan on November 28, 2017, 10:35:48 AM ---I don't see a negative orbital vector. Perhaps a 0 vector but not a 'negative' one. So with ORIS, they would give a positive orbital vector. But I don't see the type of recession or 'prominent eye' that is the 'true' indication for the ORIs. However, IF, for example, you had bi-max surgery to advance both jaws, the Lefort 1 aspect of it would leave the upper midface area (orbital rim/cheek complex) 'behind' by relative comparison.
What you have is basically a horizontal growth pattern to the jaws which means more 'compactness' to the face as opposed to 'length'. But still, the proportions, relative to each other are very good (equal '1/3rds'). I don't see any 'long' midface or relative disproportions to the bone structure.
Although your jaws might be recessed 'absolutely' like in accordance of a norm for your age and sex, it just means you might have a smaller face/head than the norm. But STILL, they look in PROPORTION to each other.
The chin contour from the front is actually great because the horizontal line to center bottom of it is what makes the face look 'angular' where the lines from lateral chin to back of jaw are 'diagonal'. I would not 'exchange' that type of angular frontal contour for a 'U' type contour which sounds like you would get with the BURRING of the chin and drop down just so an implant would better fit.
The only disproportion I see to the face is the NOSE which is too big for the face. So, you would be looking for doctors who could perform reduction rhino, not really to the bone but rather to the 'excess flesh' you have the nose.
--- End quote ---
Thanks for your detailed and informative reply. I appreciate it.
I apologize for the crummy pictures. Perhaps this one https://i.imgur.com/HHm3GbR.jpg shows what Dr. Yaremchuk mentioned to me. He told me that I had a combination of shallow orbits as well as a negative vector along with a slightly concave profile. You appear to be far better informed on this topic than I am so I'd like to ask if you see what he's talking about from this picture.
Perhaps it's then my vertically long nose that is leading to the doctors believing that I have a long midface??
I would like to ask a few questions about the jaw recession. I unfortunately never got a straight answer out of my docs, not even how they came to the conclusion that I have recessed jaws. I have read about the nasion and point A. I'm not sure where my nasion is since I do have a 'bumpy' forehead. From what I gather my chin is slightly in front of Point A, which might be in line Dr. Yaremchuk's statement that my profile is somewhat concave. I'm guessing that the angulation of my upper incisors is the camouflage treatment my original orthodontist gave me when I was 11 to fix my underbite, correct? When I view other ceph's I notice that most of the time the top of the roots of the incisors are slightly in front of the orbital bone, mine are further back. Could this perhaps point towards some recession/retrusion of the maxilla?
Thanks for the information on the burring of the bone. Yeah, I might want to reconsider that. I want to add one last picture taken by my orthodontist and I also showed this picture to Dr. Yaremchuk which led to his statement about jaw implants and also telling me that my face is quite narrow. My orthodontist told me to try to smile/expose my teeth as much as possible so it looks unnatural. https://i.imgur.com/G4xZyqm.jpg Yaremchuk said that he could tell that my jaws were too narrow because when most people smile the back of the mandible 'sticks out' a bit. My ramus and back of the jaw curves inward, which is also somewhat evident from my frontal picture. I'm not willing to take too many risks here, but would you agree with his assessment that my jaw is too narrow for my face? Could this be a result of incorrect tongue posture as a kid?
Thanks again for your time.
kavan:
--- Quote from: surgeryadvice on November 28, 2017, 09:50:16 PM ---Thanks for your detailed and informative reply. I appreciate it.
I apologize for the crummy pictures. Perhaps this one https://i.imgur.com/HHm3GbR.jpg shows what Dr. Yaremchuk mentioned to me. He told me that I had a combination of shallow orbits as well as a negative vector along with a slightly concave profile. You appear to be far better informed on this topic than I am so I'd like to ask if you see what he's talking about from this picture.
Perhaps it's then my vertically long nose that is leading to the doctors believing that I have a long midface??
I would like to ask a few questions about the jaw recession. I unfortunately never got a straight answer out of my docs, not even how they came to the conclusion that I have recessed jaws. I have read about the nasion and point A. I'm not sure where my nasion is since I do have a 'bumpy' forehead. From what I gather my chin is slightly in front of Point A, which might be in line Dr. Yaremchuk's statement that my profile is somewhat concave. I'm guessing that the angulation of my upper incisors is the camouflage treatment my original orthodontist gave me when I was 11 to fix my underbite, correct? When I view other ceph's I notice that most of the time the top of the roots of the incisors are slightly in front of the orbital bone, mine are further back. Could this perhaps point towards some recession/retrusion of the maxilla?
Thanks for the information on the burring of the bone. Yeah, I might want to reconsider that. I want to add one last picture taken by my orthodontist and I also showed this picture to Dr. Yaremchuk which led to his statement about jaw implants and also telling me that my face is quite narrow. My orthodontist told me to try to smile/expose my teeth as much as possible so it looks unnatural. https://i.imgur.com/G4xZyqm.jpg Yaremchuk said that he could tell that my jaws were too narrow because when most people smile the back of the mandible 'sticks out' a bit. My ramus and back of the jaw curves inward, which is also somewhat evident from my frontal picture. I'm not willing to take too many risks here, but would you agree with his assessment that my jaw is too narrow for my face? Could this be a result of incorrect tongue posture as a kid?
Thanks again for your time.
--- End quote ---
OK,prior, i said you had pretty much a 0 vector. That photo shows a bit less than a 0 vector. But I would not call that 'prominent' or 'buldging' eye. But still, you could have the ORIs. A midface lift goes with them as he has to re-hoist the soft tissue to a higher level for fixation. From the photo, it looks like you have enough of a sagittal cheek curve at a LOWER LEVEL that could be hoisted up with the midface lift that 'goes' with the ORIS. That would give you an improved sagittal curve.
No idea why they are telling you 'long' midface. My relative measures (on front face photo) kicked up equal '1/3rds'.
As to where your nasion is, 'N point', along with A, B, S and Pog points, I've marked out approx where they are on your ceph. I'm getting approx norms for the angle measures albeit with hand held protractor, hence APPROX. These are just relative angle relationship measures. As I said prior, perhaps the doctors are using an 'absolute' measure to tell you both jaws are recessed. Relative to a straight vertical dropped from N point, you don't see relative recession. Even if you drop a vertical from forehead prominence, you still have a good line up.
For example, let's say there is an 'absolute' distance between S and N (for a given angle) and your distance is less than that absolute. Well, then you could say both jaws would be 'recessed' according to an absolute.
[From what I gather my chin is slightly in front of Point A, which might be in line Dr. Yaremchuk's statement that my profile is somewhat concave. ]
Chin point (Pog) being slightly in front of A point AFAIK is not how they look at recession of maxilla. They look at ANB angle.
With regard to Dr. Jamali telling you that surgical corrections for your case would be 'difficult' and very risky, there would be no way for you to tell IF that were true for another max-fax with more experience and advanced skill set. For example, Gunson is considered one of the best in the US and is known for doing some advanced manuever displacements run of the mill max fax docs don't do. Yet Jamali did not give that referral to explore.
That said IF you wanted to FURTHER explore max-fax option, now that you have info that Jamali told you it was 'difficult', a good cross reference for that IN TERMS of doctors who DO the bi-max surgery would be to consult with Gunson who can do 'difficult' things or movements that are 'difficult' for other max fax docs to do.
Since a Lefort 1 would leave the ORIS and cheeks 'behind' IF you opted for bi-max. Nothing wrong with getting the ORIS now if you wanted. They would not interfere with a later decision to get the bi-max. Chin and jaw implants would interfere with it though.
BUt IF you really WANT bi-max and GAVE UP on the possibility based on what Jamali told you BUT later found out (after you had chin and jaw implants) that you COULD HAVE had the bi max (with a more experienced max fax than Jamali), best to cross reference is opinion with Gunson.
You could have jaw implants to make your jaw to jaw distance wider. But if they have to also be dropped lower to do that, the chin would also need to be altered with implants to blend. As i said, you have a nice horizontal line base to the chin which makes your face in repose look angular from the front. I have no idea if the 'bony irregularities' to your chin he refers to is the SAME straight line contour to the chin base that I think look great and/or if those are things he would need to burr down so an implant with base of an ARC would fit better. If that's the case, you could just get a wider ARC to the lower face in exchange for the angularity you presently have.
So, I guess it depends on whether or not you gave up on further exploring the bi-max option based on what Jamali told you or just resolved never to have bi-max and want your face built up with implants.
My personal opinion would be to start with the ORIS and re-evaluate the other implant options or other possible options for bi-max later. The ORIS would give some improvement and blend in with the rest of your face AS IS. You don't want a situation where if he puts in cheek implants, he THEN ALSO has to put in other midface implants below that to match with them and if he does that, then the lower face will look too narrow and recessed by comparison and then, the jaw and chin implants have to put in to match that or do you?
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