Am I a good candidate for double jaw surgery?

[Kambrook]

My interest in jaw surgery is primarily aesthetic. My upper and lower jaw (particularly the latter) are recessed and my neck-chin distance is very short. I believe I need BSSO and LeFort 1 to resolve these issues. Please see the attached photos (I've attempted to draw the Frankfort line on one but have probably done so incorrectly). But there are a couple of problems. Firstly, neither the public system nor my insurance would cover surgery purely for cosmetic reasons. Double jaw surgery is prohibitively expensive here in New Zealand -- at least 40k USD in total. Secondly, after having read of others' experiences -- the pain, the months of recovery, the constantly vomiting with jaw wired shut, etc. -- I would actually be reluctant to get the surgery for aesthetic reasons alone (especially since the improvement would be unlikely to make a significant difference in my life). So, before I go any further with this I want to firmly establish that I have a real medical need for this surgery.

Some background: my bite is fine, I don't experience jaw pain or headaches and I've never worn braces. So, I think that covers most of the issues that would cause someone to undergo jaw surgery for non-aesthetic reasons (please tell me if I've left anything out). However, the fact that I don't experience these problems currently doesn't mean that they won't become an issue latter in life (I'm 30) -- I've read about previously asymptomatic people in their fifties having these symptoms that no Doctor could find the cause of until they were seen by an orthognathic surgeon.

Also, it's come to my attention that it's entirely possible to suffer from sleep apnea without realising it. So, I'm concerned about this possibility (I sleep on my back and on my sides). If I have an orthognathic surgeon take X-rays will he be able to tell me if my airway could be restricted during sleep? Or would I be better served by a sleep clinic who can set me up with monitoring equipment? I was actually thinking of setting up my laptop with a microphone by my bed to record myself sleeping -- any snoring or disrupted breathing could then indicate possible episodes of sleep apnea.

I posted about this on RealSelf a while ago. I'll copy-paste a Doctor's response: "The lower jaw can be improved with the genioplasty to lengthen the chin height and reduce the fold under the lip/extend the flatness under the chin. The mandibular advancement is more ideal since the jaw is advanced And rotated slightly to do the same thing as above. The upper lip depends upon the angle of the upper incisors and if often improved with orthodontics when they prepare for the jaw surgery." So, this seems to indicate that, while BSSO is the best option, a sliding genioplasty would also be beneficial from a purely aesthetic standpoint. What do you think? Personally, I think the root cause of my aesthetic issues (with respect to my profile view) is that the whole lower half of my face is set back from where it should be. A sliding genioplasty wouldn't address that at all. However, it would certainly be a lot cheaper than double jaw surgery and I can see that it would help a little. Perhaps one option might be to get the SG and then consider jaw surgery if I'm not satisfied with the result?

The other thing is that I'm not really sure how to explain my situation during a consultation with an orthognathic surgeon. I think it would be very strange to simply say "I want double jaw surgery for purely aesthetic reasons but I need you to find something wrong with me so I can get it done publicly." How would you suggest I go about this?

Thanks in advance.

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[Kambrook]

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[kjohnt]

Yes*

An x ray of your teeth would be needed to see the occlusion, but I speculate:

You have a class I occlusion or near and you have both mandibular and maxillary recession.  I say this because your profile is similar to mine (except my chin doesn't project quite as far).  This means I agree with the RealSelf surgeon's theory about the mandible and chin, but it sounds like he thinks your upper incisors are tilted backward and braces would fix it, while I think they're probably sitting upright within your arch and you need maxillary advancement.  IDK regarding the CCW rotation but think likely.  Again, without an x ray, nobody could tell you.  You should definitely see an orthodontist first so you can get x rays free or cheap.  Then a sleep doctor to see if you have sleep apnea.  Then finally a good surgeon or more.

The maxillary recession is evident when looking at your upper lip / philtrum area as it goes backward then straight down instead of forward.  Forward projection there would occur if you had more upper incisor support, i.e. advanced maxilla (or tilting upper teeth upright if retroclined, and/or CCW rotation).

The mandibular recession is evident by looking at your lower lips and chin.  You are obviously aware they don't project outward enough.  Advance mandible via BSSO.

Chin needs lengthened via sliding genio.  Projection is good with lower lip.  The BSSO (+ rotation if needed) will take care of the rest of the projection.

Note that I've seen that vertical line you drew referenced before but I don't think it really tells you anything.  I think the entire bimaxillary complex should sit in front of the forehead.  I don't understand a line from the middle of the eyebrows to the jaws.

Take for example two of the first top five pictures that show up when I Google "model male profile".  Very forward projects, very ante face.  They exhibit everything I've mentioned: upper lip support with outward projection, long mandible, chin under lower lip like yours but less labiomental crease due to length, and line that you drew would mean nothing (edit - except it would cut through their jaws so I guess that means something)

* I say yes but I think the surgery is worth it cosmetic-wise if a person feels he or she needs it.  You are not bad looking, but you can use improvement.  I can go on about this and what others think about cosmetic surgery and the various types etc., but won't.  I'll just say you have one life dude, and others (esp. with nice jaw structure) haven't lived in your shoes to know how you feel.

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[Kambrook]

Thanks for the detailed response.

it sounds like he thinks your upper incisors are tilted backward and braces would fix it, while I think they're probably sitting upright within your arch and you need maxillary advancement.

I suspect you may be right. I think my lower incisors have a lot of proclinement, hence my very deep labiomental groove.

Note that I've seen that vertical line you drew referenced before but I don't think it really tells you anything.  I think the entire bimaxillary complex should sit in front of the forehead.  I don't understand a line from the middle of the eyebrows to the jaws.

The line is the vertical Frankfort plane, but I probably haven't drawn it exactly right. I think the idea is that both the chin and the philtrum should lie on (or close to) this line (orthognathic profile). If they're ahead of it the profile is prognathic (normal among Blacks). If they're behind it the profile is retrognathic (as in my case).

Take for example two of the first top five pictures that show up when I Google "model male profile".  Very forward projects, very ante face.  They exhibit everything I've mentioned: upper lip support with outward projection, long mandible, chin under lower lip like yours but less labiomental crease due to length, and line that you drew would mean nothing (edit - except it would cut through their jaws so I guess that means something)

Personally, I'm not really a fan of antefaces (prognathic profile) - I just don't think it looks natural on Caucasians. I think the aesthetic ideal is not necessarily a huge jaw in profile but rather a well-balanced orthognathic profile. Let me give you some examples of what I want to achieve:







Do you think there's any realistic hope of me achieving anything close to the above profiles? These guys all have at least 30 mm more projection than I do (neck to chin) and I understand that any advancement over 10 mm is considered a lot.

I've attached a ghetto MS Paint "simulation" I made of what I would hope a LF1 / BSSO would turn out like for me. Do you think this is realistic at all? At a guess I would guess this represents around 5 mm of maxillary advancement, at least 20 mm mandibular advancement and CCW rotation, but I really have no idea.

Thanks again.

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[kjohnt]

I've studied cephalometric analysis more and realize that vertical line drawn down from the nasion is commonly used.  I think your morph is definitely doable and I think you understand your issues, though you really need to get a cephalometric x ray so you can see your bone structure.  You should consult with surgeons or orthos in your area so you can at least get one to do your own analysis.  Their analyses would be good too but I feel you are smart to do your own.  You might ask your dentist for recommendations regarding surgeons/orthos but Google is the probably the best resource.

Note that I think you morph falls short on the upper and lower lips and the chin is still too projected relative to them.  Sliding the chin down and back would mean less projection and more vertical length, both of which would decrease the sulcus.  More advancement via bsso and lf1, though I do like the anteface look.

[notrain]

To be honest, your facial structure looks like short face syndrome: deep labiom. fold, prominent chin, recessed lower jaw, poor cervico mental angle.

The cure would by a bimaxillary advancement with clockwise rotation. http://pocketdentistry.com/23-short-face-growth-patterns-maxillomandibular-deficiency/

[kjohnt]

I think only the chin needs vertical lengthening.  I'd have to see a ceph but it doesn't appear CW rotation is the answer, as that would further worsen the cervicomental angle.

[toddstratt]

I have a very similar deformity to yours OP, also suspect short face syndrome in my own case. Surgery would definitely help on the aesthetic side, but I also deal with a class II overbite and overjet, as well as short palate of the upper mouth, posted in this thread about it http://jawsurgeryforums.com/index.php?topic=5158.0. You had been given x rays before and they docs told you there was no issues? Or is this your own assumption regarding your bite being fine as it is? You should definitely look into it more and get some consultanting with someone like an Ortho as well. It looks like even with your bite being fine, the kind of shape your lower jaw and mouth have, could cause some kind of possible obstructive sleep apnea, or other issues down the line.

[JayJaw]

I don't think you are accurately assessing the face's of the models you posted. They all have ante face but they have their heads tilted down, every one of them. I even believe your face is slightly down in the picture you've posted.

The whole ear/nose being level thing isn't accurate when you use the earlobe as the point of reference. Ultimately, to see what is truly level, you should look at the skeleton but the best way to do it on a person is the bottom portion of their ear hole (i.e. above the lobe) and the bottom of their nose. This, generally, seems to be the natural horizontal position. You'll notice the pictures you (and even the other person) posted all show their chin further back and their bite plane at an angle due to this head position. If you were to rotate their heads and line the bottom of ear hole and bottom of nose, it'd be in the horizontal.

In this position, both jaws should be ahead of the forehead. It won't become an overly ante face either, just balanced. If you look at pictures of even those with recessed jaws, they have a maxilla ahead of the forehead (the base of nose). You feel yours goes "backwards" but I suspect it is simply straight down and has no projection from forehead. Ultimately, the same conclusion is drawn though... definitely recessed maxilla (and similarly recessed mandible).

I hope that makes sense but I just feel people through around pictures and I'm not sure are looking at the vertical/horizontal properly.

Then again... I'm no expert and could be wrong!

[Kambrook]

In this position, both jaws should be ahead of the forehead. It won't become an overly ante face either, just balanced. If you look at pictures of even those with recessed jaws, they have a maxilla ahead of the forehead (the base of nose).

Right, when I talk about antefaces I mean significant prognathism. This is a natural feature among those of African descent, but I think an orthognathic profile (such as those shown in the images I posted above) is the most natural and aesthetic for Caucasians.

You had been given x rays before and they docs told you there was no issues? Or is this your own assumption regarding your bite being fine as it is? You should definitely look into it more and get some consultanting with someone like an Ortho as well. It looks like even with your bite being fine, the kind of shape your lower jaw and mouth have, could cause some kind of possible obstructive sleep apnea, or other issues down the line.

Well, I saw a Dentist regularly through my childhood and teens and they never suggested that I needed orthodontics. I also have no issues with TMJ, headaches, I can eat normally, etc.

Yes, I'm concerned about sleep apnea. I may already be suffering from it for all I know. In a perverse way, I'm actually hoping it is an issue for me so that I can get my surgery covered by insurance (or the state) and thus save myself $50k+ 

To be honest, your facial structure looks like short face syndrome: deep labiom. fold, prominent chin, recessed lower jaw, poor cervico mental angle.

Really? I have a pretty long face -- long nose, long philtrum, etc. -- whereas the short face syndrome cases I've seen have the opposite problem of a vertically compressed appearance.

Note that I think you morph falls short on the upper and lower lips and the chin is still too projected relative to them.  Sliding the chin down and back would mean less projection and more vertical length, both of which would decrease the sulcus.  More advancement via bsso and lf1, though I do like the anteface look.

Yes, I didn't touch the lips in my morph. The orthodontics and sliding genio should improve the contour of my lower lip (and produce a far more pleasing labiomental groove) and the maxillary advancement should hopefully give my philtrum a nice concavity. I don't know if I could really reduce the frontal projection of my chin as I think I'm really relying on that to give me extra projection to my jaw. Obviously a witch's chin isn't ideal but I think it's better tolerated in males than in females.

I guess my main concern at this stage is the effect the surgery would have on my 3/4 and frontal aesthetics. The potential improvements to my profile are obvious (besides resolving possible functional issues) but I'm concerned that these may be outweighed by adverse changes to my face from any other view (which I would regard as more important). I think the main issue would be the cheekbones. I already have pretty shallow cheekbones, so moving my whole lower face forward while keeping my cheekbones in the same place is only gong to aggravate that. My current 3/4 contour is just about a straight line (at, I would guess, around 25% bodyfat). After moving the maxilla forward ~5 mm I would expect that my 3/4 contour would be decidedly convex, even at low bodyfat. The frontal view would likely suffer similarly. What do you think?

The other issue is the changes to soft tissue and the nose. It seems to be inevitable that advancing the maxilla causes the nostrils to broaden and the nose to become more upturned, the degree of change being approximately proportional to the degree of advancement. I found a really interesting paper on it: https://www.researchgate.net/publication/51114020_Nasolabial_Changes_After_Maxillary_Advancement. This paper suggests that an advancement of around 5 mm should increase the alar width by roughly a third of a millimeter, which seems a bit optimistic considering some of the before and afters I've seen. I'm currently in the process of finding as many before and after photos as I can (that are comparable to my situation) in order to get a good idea of what changes might occur.

I've attached before-afters of a guy who had a pretty good result from only a 10 mm BSSO (from http://pocketdentistry.com/19-aesthetic-benefits-of-orthognathic-surgery/). Not only is his profile improved, but his double chin is gone and his soft tissue in general is much improved -- he really looks a lot younger. Obviously I have maxillary issues that he doesn't have but I'm hoping my aesthetics would be similarly improved.

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[kjohnt]

The example posted is another case in which the chin should have been brought down and back.

[Kambrook]

The example posted is another case in which the chin should have been brought down and back.

Agreed. There's a cruel irony in the fact that the only part of my face that has decent projection has too much of it

[PloskoPlus]

You'd be insane to have jaw surgery in NZ even for free, unless you had a horrible starting point (a really bad malocclusion - so a mediocre result would still be better than doing nothing).   The population is tiny, as would be the experience of the surgeons.  Most of your guys end up across the pond here.  And even then the volume they have here is probably nothing compared with the volumes of top American surgeons.  A top surgeon here left me with a permanently numb upper lip (never heard of this happen before it happened to me).  If you don't believe me about NZ surgeons, contact Ben30.