What do I need? (Pics, Ceph+)

[Lazlo]

Yeah it's tough, a lot of us are spending our life's savings on this surgery, so that's just the way it goes. Some people get 3-4 jobs working simultaneously to pay for these things. That's the norm on this board, unless you're like megawealthy.

And yup, bi-max with chin-wing, genio is the fix, but that's what it'll take with a primo surgeon.

About the change of resin fillings to amalgam --did teeth sensitivity change? And how much did it cost? That's a selfish question on my part since I'd maybe like to have that done down the road. Made your mouth look so much better.

I dunno, I wouldn't even bother with the rhino till you're all done with everything else.

Man your rhino doc seems to have followed all protocol, but you still got some pretty serious rotation of the tip and alar shrinkage. Did you ask for a small upturned nose? Did he show you any sort of visualization or imaging of what your nose would look like? Like did you guys come up with a desired outcome, visually, together? I'm curious what the process was like for you because if so, this would just be an unfortunate case of post-rhinoplasty problems.

The real truth no one tells you. Almost 50 percent maybe higher, of rhinoplasties require revision, and part of that is cause it's just a really, really unpredictable procedure --except in really simple cases where someone has thin skin and just wants their hump removed or something like that.

[SJay]

I don't think your rhino was a complete disaster, my primary was a lot worse, and in some ways it's an improvement! It does also depend on one's aesthetic taste, but I'm kind of with Lazlo here... I prefer a stronger bridge and a lower, slightly pointy tip for a man. I think Johnny Depp has the perfect male nose, strong but not too strong.

Here's my two cents... I think the dorsal hump needed to be conservatively shaved down. This was made more apparent by the low radix, which could have been elevated slightly. Your tip was slightly too low, and did need to be conservatively lifted, hence the columellar strut graft. Your surgery did not leave you with an inverted v deformity and your mid vault hasn't caved in, which is a common issue with such a reduction in the bridge, and this is all thanks to the spreader grafts. If you were going to revise the nose, I would elevate the bridge slightly with an onlay graft, have the alar rims pulled down, and have the columellar tucked in. I wouldn't formally derotate the tip as it will naturally look lower and less projected once the bridge is elevated and the columellar tucked. The onlay and the columellar tuck should be simple procedures, but I'm guessing all your septal cartilage was taken for grafting in the primary. You would therefore need to use costal cartilage from the chest wall, which should not be taken lightly as it will leave a scar of significant length, and in the worse case lead to a punctured lung. Alternatively, you could use a gortex implant but these are prone to infection, or donor cartilage but these are had to work with and often warp. Ultimately, your nose is not a disaster, it could be improved but it would be costly with potential complications.

I appreciate that you may not agree with my comments, and I hope you take them in a constructive way. If you do go for a revision, be very careful who you pick as you don't want to make matters worse.

[Lazlo]

If anythign you're being super helpful SJ by sharing your experiences, taste and expertise.

[ditterbo]

I went with my op doc because he seemed to understand nasal anatomy extremely well, seemed like a perfectionist, and conservative. He specializes in revision rhinoplasties and has I think 15-20 years experience.  However, he's just a PS and has his limitations that you find out on your own if you're not careful enough.  I didn't look at pictures of his other patients, and we only discussed the problem areas and how he'd change them in surgery - bulbous tip, nasal valve collapse, high bridge (iirc).  He actually stressed he'd have to be careful how much he reduced because he saw my nose could quickly become too feminine. I'm not sure why but I don't see my nose, in-person, quite as upturned as it looks in those post op profile shots.  The bridge also seems bigger in person, but I think everything's being distorted, in my eyes, by the retracted rims and hanging columella.  In most ways (except the bridge), my nose actually seems bigger to me than before.

That said, I hated my old nose for a variety of reasons, so this one is an OK improvement to me.  IF I decide against jaw surgery and just to fix my nose, and IF I have any septal cartiledge left to spare, I'd probably forego the onlay graft and just fix the columellar and retracted alar rims. Would a CT scan show how much septum is left?  Does tucking in the columellar afford me with spare cartilage as well?   Thanks for all that specific feedback SJ! That has probably saved me weeks of research for that future date when I reassess my nose situation. 

Honestly the big problem is I have a bone spur in my left septum that is super annoying. I haven't had such breathing problems through my left nostril before.  An ENT thinks the bone spur may be causing a deviated septum, pushing it into the left airway.

[ditterbo]

Yeah it's tough, a lot of us are spending our life's savings on this surgery, so that's just the way it goes. Some people get 3-4 jobs working simultaneously to pay for these things. That's the norm on this board, unless you're like megawealthy.

And yup, bi-max with chin-wing, genio is the fix, but that's what it'll take with a primo surgeon.

About the change of resin fillings to amalgam --did teeth sensitivity change? And how much did it cost? That's a selfish question on my part since I'd maybe like to have that done down the road. Made your mouth look so much better.

I dunno, I wouldn't even bother with the rhino till you're all done with everything else.

Every max facs I've seen, except Posnick & A&G, have advised against anything more than an SG.  Dr. Harrison Lee, who used to do jaw surgery, insisted I'd get "very little" cosmetic improvement from bimax.  I wonder if most max facs just don't know how to do 15mm+ BSSO's, CCW's, etc.. 

Also seeing an old forum post raised back up here, and it's just made me realize my gonial angle is horrendous.  That's one area I'd probably want addressed at the same time as bimax, however possible.

The change over to composite resin fillings was several years ago, but I don't recall much change in teeth sensitivity.  One of the molar fillings hurts my tooth sometimes if I chew into something hard.  Maybe has to do with how the filling is in a pressure point on the tooth.

I confirmed with my insurance that jaw surgery is reimbursable if deemed medically necessary, so maybe between Gunson's and Posnick's analysis, I'll have a case.  Also maybe Dr. Sinn is worth a look?  Again though I'm in Washington DC...

[SJay]

Your surgeon should know exactly how much septal cartilage you have left for grafting. They can't take it all as some is obviously needed. I don't think tucking the columellar will free up any useable cartilage. If you're happy with the bridge, then there's enough cartilage in the ear to take a small graft for the nostrils. In fact, my surgeon was able to fix my nostrils without rim grafts, he simply repositioned the existing lower lateral cartilages, so it depends on what's causing the problem. If you're happy with your nose, then it's probably best to leave well alone.

[SJay]

Regarding the bi-max, I suspect that's a significant factor. If you go to a surgeon with a limited toolkit, sadly most don't have the decency to point you in the direction of someone more able, but instead try to sell you something they can do. They need the business, and they don't want you going to the competition. It's a simple problem of incentives, and theirs are certainly not the same as yours. You've got to look out for yourself, and therefore go to a highly skilled surgeon with a very large toolkit. This way, they have all options available to them and can select the one which is actually best for you, and not constricted to their limited ability.

[Bobbit]

Regarding the bi-max, I suspect that's a significant factor. If you go to a surgeon with a limited toolkit, sadly most don't have the decency to point you in the direction of someone more able, but instead try to sell you something they can do. They need the business, and they don't want you going to the competition. It's a simple problem of incentives, and theirs are certainly not the same as yours. You've got to look out for yourself, and therefore go to a highly skilled surgeon with a very large toolkit. This way, they have all options available to them and can select the one which is actually best for you, and not constricted to their limited ability.

This.  Needs to be front and center in your thinking !

[Tezcatli]

Every max facs I've seen, except Posnick & A&G, have advised against anything more than an SG.  Dr. Harrison Lee, who used to do jaw surgery, insisted I'd get "very little" cosmetic improvement from bimax.  I wonder if most max facs just don't know how to do 15mm+ BSSO's, CCW's, etc.. 

Also seeing an old forum post raised back up here, and it's just made me realize my gonial angle is horrendous.  That's one area I'd probably want addressed at the same time as bimax, however possible.

The change over to composite resin fillings was several years ago, but I don't recall much change in teeth sensitivity.  One of the molar fillings hurts my tooth sometimes if I chew into something hard.  Maybe has to do with how the filling is in a pressure point on the tooth.

I confirmed with my insurance that jaw surgery is reimbursable if deemed medically necessary, so maybe between Gunson's and Posnick's analysis, I'll have a case.  I presume you recommend consulting Dr. Sinn?

Plastic surgeons usually love implants and dislike jaw surgery. In the US apparently there is some overlap between the two as some PS also do jaw surgery but if you go to a guy who is a maxfac first and foremost like Posnick you should have better results.

In Brazil maxfacs don't go to med school but follow a different path becoming a dentist first as an "undergrad"(5 year university course after high school instead of 4 year college) and learning surgery later as a grad and they have completely different approach from the MD plastic surgeons.

When I got my rhino my PS was pretty good at it but I told him about my jaw problems and he said I didn't need anything and how jaw surgery was bad, I should consider an implant, he was also wearing a fancy suit and looked like a douchebag.

I went to a maxfac later and he was extremely professional like you expect from a doctor and explained me in details how orthognatic surgery could help me and he said he is against implants except when there is a complete lack of bone due to a gunshot or similar.

[PloskoPlus]

Regarding the bi-max, I suspect that's a significant factor. If you go to a surgeon with a limited toolkit, sadly most don't have the decency to point you in the direction of someone more able, but instead try to sell you something they can do. They need the business, and they don't want you going to the competition. It's a simple problem of incentives, and theirs are certainly not the same as yours. You've got to look out for yourself, and therefore go to a highly skilled surgeon with a very large toolkit. This way, they have all options available to them and can select the one which is actually best for you, and not constricted to their limited ability.

These super surgeons don't exist.

[PloskoPlus]

Every max facs I've seen, except Posnick & A&G, have advised against anything more than an SG.  Dr. Harrison Lee, who used to do jaw surgery, insisted I'd get "very little" cosmetic improvement from bimax.  I wonder if most max facs just don't know how to do 15mm+ BSSO's, CCW's, etc.. 

I've seen a picture of a bi-max on a guy with something like 12mm BSSO and 7 mm LF1 advancement.  He looked hardly different.  I think it depends on the case.  In general, the cases where CCW was required but was not performed are the ones that look like "what was the point?".

The common refrain regarding CCW is that it's "unstable".  I am not sure what it means - perhaps the down graft of the posterior maxilla?  But then many surgeons do CW with down grafts for short face syndromes.  The man who invented CCW says the reason it's not done more often is that the people who need it the most often have joint problems, and if they are not addressed, CCW will make the problem worse.

Personally, I think it's because CCW is just plain hard to do.  You have multiple movements in 2 dimensions (3 if a 3-piece LF1 is done) and everything is just floating there.  To get it all right is hard.  And then you have to factor in minor relapse post surgery - e.g. posterior maxilla downdraft relapses by 1 mm - what effect does this have on the bite? etc..  It's much easier to just move things forward and back.

IMO, you should leave the nose alone until you're done with jaw surgery.  Ideally, you should have not done anything with it until after jaw surgery.  The nose changes a lot due to surgery.  The tip often goes up - may be controlled with anterior nasal spine reduction, but in some cases it may be a good thing, and it would be balanced by a more forward chin in your case anyway.
The nostrils flare a bit - this may be controlled by an alar cinch.  But one thing that cannot be controlled is the fact that your cheeks come forward due to the LF1 and the nose just looks smaller in profile even if the tip goes up and it becomes more projected.  This completely changes the way your nose looks in profile.  You may have not needed any bridge reduction at all had your cheeks been more forward.

[kjohnt]

^ I don't agree about the cheeks coming forward, but I agree the advanced maxilla can actual makes some peoples' noses look better, and I certainly agree that if getting jaw surgery, one should hold off on rhino or any other work until afterward.

For me personally, regarding implants... I just don't like them.  The possible infections, possible shifting, and thinking about having an implant under my skin kind of gives me the creeps for some reason (though fixation screws and plates seem okay to me so IDK why that is).  Aside from rhino if somebody needs it, I think any facial issues are ideally addressed with surgical bone movement.  It sure would be nice if there was an easy way to get wider gonial angles via max facs though.

[Tezcatli]

I've seen a picture of a bi-max on a guy with something like 12mm BSSO and 7 mm LF1 advancement.  He looked hardly different.  I think it depends on the case.  In general, the cases where CCW was required but was not performed are the ones that look like "what was the point?".

Do you have pics? On the very least he doesn't have an underbite anymore.


About the nose looking smaller, I hope it does, even after rhino which removed the hump my nose is still extremely big. However I'm glad the surgeon didn't give me a little upturned nose as it would look bad after the Lefort.

[PloskoPlus]

Do you have pics? On the very least he doesn't have an underbite anymore.

He was class ii before. I think he just had a very retrognathic face in general. He looked virtually the same afterwards.

[ditterbo]

I bet my chin will look worse after I get this revision in a week.  The implant will probably follow my steep jaw angle, unlike my current one.  I haven't read into exactly how CCW works, but I think my op doc intentionally angled my current implant 'forward', as if to give my chin CCW rotation.  Problem with that is, I suspect that's a big reason why my lower lip is tethered up.

I agree with everyone on dropping the implant route, but I can't wrap my mind around spending 50k+ on bimax surgery.  I just don't want this badly enough to go through the whole ordeal AND empty out my life savings.  Until I can find a more reasonably priced  doctor without sacrificing quality, or I get some insurance coverage, bimax seems like a distant dream. 

A part of me hopes a morph from like Dr. Gunson will show me how I would look *so* much better with bimax, and convince me it's worth the investment.  But I'm also aware of how my whole face is recessive and would probably need more bone work to really start looking any good.

The way I see things, I've gotten a decent paying job and scraps of a social life despite these cosmetic issues and other factors.  I'm afraid jaw surgery will completely throw me overboard and lose everything I've built up so far. They say (out here on the east coast anyways) that once you take off from work a month or more, you never really return.     

EDIT: Is my rationale reasonable here, or have I already gone off the deep end?