Revision zygomatic osteotomy: anyone?

[Lazlo]

I was referring to the multitude of PSs advising obviously recessed people on real self to get rhino and chin implants.  This makes them either fools or liars. Neither reflects well on the industry.

Kinda have to agree w/ Plosko and Facenit on this one. It's a shifty profession intrinsically. Surgeons cut whether it's needed or not.

[Bobbit]

I was referring to the multitude of PSs advising obviously recessed people on real self to get rhino and chin implants.  This makes them either fools or liars. Neither reflects well on the industry.

Plosko ( & Lazlo ) ,

Sorry - -  Plosko, my mistake.  I took your comment as a general broad side at all plastic surgeons.   I have not spent any significant time at the real self location - - but if surgeons are making those kinds of recommendations - -  then that does not reflect well on those surgeons. 

One thought - -  one needs to be careful because there are also  "surgeons" who show up on a lot of lists like that  and claim to be Plastic Surgeons - -  but they are really only something much less in terms of training and skill sets  - -  when you look carefully at their web sites or they otherwise get pressed on the issue, they then fall back and say they are really  "cosmetic surgeons" but they are just as good doing cosmetic surgery  as real plastic surgeons because they did not waste a lot of time in training learning to fix hands and jaws and trauma and learning to take care of burn patients,  etc.   

[ Apparently,  there is a racetrack program for people to do a one-year general surgery residence gig and then a one-year "fellowship" in cosmetic surgery at a non accredited program somewhere - -  and then claim they are "cosmetic surgeons" and therefore they are instantly as well trained to do cosmetic surgery (noses and chin implants, for example) as  board certified plastic surgeons who spent 7 or 8 or 9 years in training.  It is possible that is where a lot of those kinds of recommendations come from.]

 

[Lazlo]

Any MD can claim to be a "cosmetic surgeon" or "cosmetic specialist". You have to look for "plastic surgeon," that's a craniofacial surgeon  --they can do jaw surgery any time of skull surgery --but that still doesn't mean they're good.


As I said before most surgeons will push ahead with what they can do on you whether it's needed or not. I could go to a cosmetic surgeon who only does maybe nosejobs and facelifts and say "meh meh blah blah my face is saggy and doesn't have good angles." And thy might recommend a facelift to tighten the soft tissue, or little implants that will look like crap, cause they don't know how to change the bones or skull. And they I'll end up looking like a mugwump gism cause I didn't know any better and the surgeon will be like "you look fine, you asked for the procedure!"
This is what I mean by they're intrinsically shifty people.

No surgeon or very few will be like "no you don't need what I know how to do, you need a jaw surgery with a maxillofacial surgeon," or something like that. I've now seen many, many cosmetic and plastic surgeons and they always just say "no it's not possible" if you ask for something they don't know how to do. Even Arnett and Gunson, asked them about cheekbones. They actually told me "no that can't be done it's too unstable, we do HA Paste that will give you the higher cheekbones don't worry," and of course that is bulls**t. So you have to be in control of your own self and your own surgery. research, research, research more, and then finally takee th plunge. Risk is unavoidable.

[Bobbit]

Any MD can claim to be a "cosmetic surgeon" or "cosmetic specialist". You have to look for "plastic surgeon," that's a craniofacial surgeon  --they can do jaw surgery any time of skull surgery --but that still doesn't mean they're good.


 . . .  I've now seen many, many cosmetic and plastic surgeons and they always just say "no it's not possible" if you ask for something they don't know how to do. Even Arnett and Gunson, asked them about cheekbones. They actually told me "no that can't be done it's too unstable, we do HA Paste that will give you the higher cheekbones don't worry," and of course that is bulls**t. So you have to be in control of your own self and your own surgery. research, research, research more, and then finally takee th plunge. Risk is unavoidable.

Correct me if I am wrong,  but Arnett & Gunson are not plastic surgeons.  And, they are not craniofacial surgeons.  Neither is Sinn - -  right ?

So sure - -  their options for doing surgery to meet your specific needs may be limited.

OTOH - -  none of them should tell you "something can't be done"  merely because they do not do that procedure.  They should know better. 

Because you have studied the heck out of this subject,  this likely does not apply to your situation,  but, for many patients,  I suspect that sometimes it is a fine line between hearing something like:

  " That procedure can't be done but I have an alternative that I do routinely that will fix you right up the way you want."

               opposed to  something like

 "While I do not do that procedure,  I am very familiar with that procedure and it is not appropriate for your needs - -" 

[PloskoPlus]

Sinn is also a craniofacial surgeon.

[Bobbit]

Sinn is also a craniofacial surgeon.

Plosko,

Looked again at his web site,  Dr. Sinn is very well qualified and very experienced as a maxillofacial surgeon.  And from his list of publications, he has done a lot of work with other craniofacial surgeons that did involve various craniofacial procedures.  However, he is trained as a dentist.  Without a medical degree and a subsequently completed surgical residency,  it is unlikely that he could acquire privileges at a hospital to be lead surgeon on a major craniofacial case - -  unless it was a surgery that was clearly limited to only involve work in or about the jaws.

Unless I missed it somewhere, he does not explicitly claim to be or to be trained as a craniofacial surgeon anywhere I could find on his web site. 

Apparently very good at what he does.   

[PloskoPlus]

I think you're right about Sinns qualifications.  But he has published chapters on craniofacial syndromes and regularly treats them.  He does box osteotomies.  How much more craniofacial does it get?  Many so called craniofacial plastic surgeons have never done anything more complicated than a rhinoplasty.

[Lazlo]

Since taught Arnett and Schendel. I know about his qualifications. His supreme focus is specifically jaw surgery. He's an exception to the qualification thing cause he's a guy who basically was one of the inventors in the field.

[PloskoPlus]

Since taught Arnett and Schendel. I know about his qualifications. His supreme focus is specifically jaw surgery. He's an exception to the qualification thing cause he's a guy who basically was one of the inventors in the field.

Pretty much this. My surgeon learned orthognathic surgery from his book - one of the first on the subject. Dallas is where they first combined orthognathic surgery with braces.

[Bobbit]

I think you're right about Sinns qualifications.  But he has published chapters on craniofacial syndromes and regularly treats them.  He does box osteotomies.  How much more craniofacial does it get?  Many so called craniofacial plastic surgeons have never done anything more complicated than a rhinoplasty.

The box osteotomies  or the later derivatives of those are part of the big surgeries in the tool box.  I did not see anywhere on his web site any suggestion that he did those, but if he is doing that type of work as the lead surgeon on those, then that is certainly part of the tool set of craniofacial surgeons.  Other than massive trauma, the big surgeries that the craniofacial surgeons do  include  surgeries where they re-model the entire skull (not just the orbital areas)  to correct deformities and or to increase the skull volume to allow brain growth in infants and small children. 

It is my understanding that all plastic surgery training programs give some exposure to the craniofacial procedures - -  but the only ones that are actually qualified as craniofacial surgeons and could get hospital privileges to do those surgeries are the ones that (after finishing their full 5 or 6 year surgery-plastic surgery training) then also find a traditional full one year fellowship program devoted to craniofacial surgery that is sanctioned by one of the medical education supervisory groups.   (You probably know this, but for others, google up  Paul Tessier and maybe Daniel Marchac ) and read Tessier's history to get an idea of how complex those surgeries can be.   Pretty sure that it is generally true that very nearly every single surgeon in the world today that legitimately claims to be a craniofacial surgeon was trained by Tessier (or Marchac,)  or else trained directly by someone that had previously themselves been trained by either Tessier or Marchac.  More of them probably trace back to Tessier.

  (  read a biography of Tessier a couple of years ago. Fascinating what he had to go through to learn how to do those. )

[Lazlo]

When you're dealing with Wolford, Sinn etc. normal rules don't apply. These guys are the pioneers. They could do craniofacial surgery or almost any surgery in their sleep. Like Arnett they are in the category of "supersurgeon". It's the young MD's who have maybe a year of surgery experience that suddenly start providing every cosmetic surgery under the sun who are scumbags.

Yeah Dallas has a huge craniofacial institutte where the most advanced things are done. It's where every ortho and surgeon goes to learn. Also maxillofacial surgeons specialize in jaws but they can do any craniofacial surgery as they are trained in treating and maxillofacial trauma eg. cheebones, cleft palate etc.

So like Sinn can do nosejobs, and he suggested, but I know there are surgeons who only do rhinoplasties --I'm more likely to go with one of those eg. Dr. Guyron, Dr. Gregroyantis, etc. just cause that's all they do and have developed procedures for those areas.

Anyway, Sinn is definitely the boss.

[hellohello]

FaceNit was spot on in one of her previous posts.
I don't have maxillary retrusion. However, most often recession is not just limited to part of the (lower) midface. If the lower part of the zygomatic bone is recessed; often the upper part of the zygomatic bone doesn't have strong projection either. If you have a recessed lower zygomatic bone, then most likely that recession extends upwards towards the inferior orbital rim, and/or it is not unlikely that the medial and lateral inferior orbital rim would be partly recessed to. In my case: the lateral part of the zygoma above the malar prominence is recessed, as is the lateral inferior orbital rim.

In general, to get 'high cheekbones' not just the lower part of the zygomatic bone should be addressed (unless the upper part has strong projection naturally). And the zygomatic sandwich osteotomy augments only the lower part of the zygomatic bone. If you look at the cuts made for the zygomatic sandwich osteotomy, you can see only the lower part of the zygomatic bone is moved. Not the upper part of the zygomatic bone (extending towrds the inferior orbital rim, and/or the inferior orbital rim itself).

Reading a bit up on the forum, sometimes it is suggested to get a zygomatic sandwich osteotomy to get strong, high cheekbones. However the zygomatic sandwich osteotomy will not yield that aesthetic result of high cheekbones, unless you already have strong projection above the malar prominence towards the inferior orbital rim (and strong medial and lateral orbital rims) naturally. (Which is not at all that likely if the lower zygomatic bone is recessed. Since, as written above: if you have recessed lower zygomatic bones, most likely you will have some recession of a bigger part of the zygomatic bone, such as the upper part of the zygomatic bone extending towards the inferior orbital rims, and/or along the orbital rims themselves).
If you are hoping to get some augmentation of the lower part of the zygomatic bone: the zygomatic sandwich osteotomy can give you some extra width and (limited) forward projection at the lower part of the zygomatic bone.

A member here underwent a lefort iii (Earl). He wrote several times the lefort i does not address the inferior orbital rim; and neither does the zygomatic sandwich osteotomy. He was absolutely right. The procedure that does address the lateral and medial inferior orbital rim, as well as the area above the malar prominence exending into the inferior orbital rim, is the (modified) lefort iii he underwent.
Rico wrote the same thing. That the zygomatic sandwich osteotomy does not address the area extending into the inferior orbital rim. You would need a different type of zygomatic osteotomy (or a (modified) lefort iii) to address that area. Some zygomatic osteotomies address the area extending towards the inferior orbital rim. However, as mentioned the zygomatic sandwich osteotomy addresses only the lower part of the zygomatic bone, and the cuts made for this type of osteotomy illustrate exactly that.

In my case 'high cheekbones' were the anticipated results. In general I don't have a deformed result or even a bad looking result. I just have augmentation/fullness of the lower part of the zygomatic bone. The upper part of the zygomatic bone, extending towards the inferior orbital rim is still recessed. (In my case mostly the lateral part, since medially I had good projection naturally/from myself). This looks like lower cheekbones rather than high cheekbones, and it is not what was anticipated. As mentioned I am unhappy.
A revision would be complex, since if I were to somehow address a broader part of the zygomatic bone with a different type of zygomatic osteotomy than the sandwich osteotomy, I now might end up with an overprojected lower zygomatic bone. Which might look awkward. After all the lower part of the zygomatic bone was aready augmented with the sandwich osteotomy and if I were to augment a bigger part of the zygomatic bone (as I would have liked in the first place), that same lower part of the zygomatic bone would be augmented once again. (Unless I would have the zygomatic sandwich osteotomy revised while getting a different zygomatic osteotomy, but that would be very complex revision and probably not worth the risk for me).

[hellohello]

All in all, if high strong cheekbones is what you are aiming for, it might be best to take the limitations of the zygomatic sandwich osteotomy into consideration and decide whether you might need a different type of osteotomy that augments a bigger part of the zygomatic bone.

[Bobbit]

When you're dealing with Wolford, Sinn etc. normal rules don't apply. These guys are the pioneers. They could do craniofacial surgery or almost any surgery in their sleep. Like Arnett they are in the category of "supersurgeon".

They are very good maxillofacial surgeons. Top of their fields. Possibly/likely pioneers in some aspects of maxillofacial jaw surgery (although almost all of those jaw surgery procedures discussed here were developed by Hugo Obwegeser in Switzerland well before they finished their training.) 
Their specialty involves jaw surgery and related issues.  Neither has completed a plastic surgery residency, a common requirement to be a craniofacial surgeon. Ultimately, neither one of those two very well trained and experienced surgical dentists/oral surgeons begin to qualify as “the pioneers” in the broader field of craniofacial surgery. 

Pioneers in craniofacial surgery: In the 1970s and 1980s, somewhat before their time, the pioneers in craniofacial surgery were in France.  Started by Tessier.  He appears to have collaborated to some extent with Hugo Obwegeser.  Later, Daniel Marchac started doing similar surgeries independently of Tessier.  The first American to figure out that there was a developing new field of surgery and to then go over to Paris (1973)  and become trained by Dr. Tessier was Douglas Ousterhout (later UCSF) .  Others followed, including Henry Kawamoto, (later UC Los Angeles),  Anthony Wolf, (Miami),  Arlen Denny,  (U Wisconsin, Milwaukee) (total of about 6 US surgeons) (Note: some caution. A number of US surgeons went over to Paris to Tessier’s to be “surgical observers” for brief periods - - but they were not “fellows” doing a full one year training program.   Others who observed Tessier operate in the US.  Some of those have made claims they were “trained” by Tessier.)  [Primary source: Anthony Wolf - Tessier’s biographer.  Good read.]

  See:  www.ascfs.org

“Craniofacial surgery is a sub-specialty of plastic surgery. It traces its beginnings to a group of surgeons who were interested in the treatment of birth defects in children involving the skull and face. In the late 1960's, Dr. Paul Tessier from Paris, France, reported on techniques he had developed to treat children with rare birth defects. Following these initial reports, many surgeons from around the world traveled to Paris to learn these new procedures.”
Neither of the very good maxillofacial surgeons you identified as “pioneers” in the field of craniofacial surgery are eligible for membership in the American Society of Craniofacial Surgery.

Again - - this is not meant to be critical in any way. First class surgeons.  Just history.

[Lazlo]

I know the entire history of craniofacial surgery and know Tessier and his pioneering work quite well. And everything you're saying is accurate as far as credentials go. But I know for a fact that Kawamoto who is arguably the most notable craniofacial surgeon in America, would not perform zygomatic or orbital rim or modified leforts on ANY patients for cosmetic purposes. I know this because I talked to his nurses several times and was recommended that Kawamoto would do implants only. So big deal if someone has all this training and a designation but doesn't feel competent or trained enough or whatever the reason may be to perform the operation.

Dr. Mark Urata, Kawamoto's most distinguished pupil both a craniofacial surgeon AND a maxillofacial surgeon also doesn't perform and orbital/cheekbone modified lefort operations for cosmetic purposes.

On the other hand, Eugene Keller (NOT A CRANIOFACIAL SURGEON) developed and practiced successful modified leforts that include the zygoma and orbital rim throughout his career.

So while yes a craniofacial designation takes a ton of training and specialization, it doesn't necessarily mean the surgeon is competent enough or willing enough or has experience in the cosmetic or plastic surgery area for most non-syndrome, non-infant (which is the type of surgery most craniofacial surgeons do) population. I too was at first very taken with the whole craniofacial designation and consulted with surgeons who had both this PS designation as well as max fac backgrounds and found some of them to be thoroughly incompetent. Won't mention names.

So I now am more interested in how many cosmetic cases a surgeon has performed, what his or her reputation might be and what professional colleagues and patients think of the surgeon in question. Also, with what regularity does the surgeon in question perform the specific surgery I'm interested in.