Surgeon’s Recommendation. Concerns + Questions

[emanresu]

Hey all,

So it’s been almost two weeks since my appointment with Dr. Caminiti, and I’ve been delaying on making an update because I've been mulling over what he told me and I'm still pretty conflicted on how to proceed.

Diagnosis: He told me that since my bite is basically perfect it’s not worth doing full-on jaw surgery due to the risks involved. He recommended a sliding genioplasty with an 8 - 9 mm advancement; he made no mention of vertical movement. Apparently my nerve is higher up and I have a broad chin bone, so he could get a higher cut and bring it out without looking pointy. He also told me that a sliding genio would move the hyoid which would improve my submental angle a bit too. He said “If a bimax with a sliding genio were to give you a 10 out of 10 result, a sliding genio alone would still give you an 8 out of 10 result.”

Being able to avoid bimax would be great, but the problem is that I’m seriously doubting a sliding genio alone could give me “8 out of 10” the results of bimax, especially to a lower third as bad as mine. I fear that Caminiti may have misdiagnosed the severity of my jaw recession due to my forward head posture and tendency to tilt my head upwards. I've uploaded new pics so you can see what I mean.

NEW PICS: http://imgur.com/a/pVPFG

• Thoughts? Do you think sliding genio is right in my case, or is Caminiti underestimating the severity of my issue and how beneficial bimax could be for me?
  
  
• Assuming Caminiti is correct (that my bite is basically perfect, and moving my jaw wouldn’t make a considerable difference) then what the hell is causing my abysmal lower third and submental angle? There’s no way it’s all because of my chin. Is it excess skin/fat? Low hyoid? Jaw size (micrognathia)? Tongue posture?
  
  
• How about a sliding genio from an aesthetic standpoint? I’m concerned that it would look strange on me because my entire lower third is so small, and a bigger chin may just make this more apparent and/or make it look even narrower. (In some weird way, I feel like my lack of a chin actually suits the rest of my facial features, and if I were to suddenly acquire a ‘normal’ chin it could incidentally just reveal how weird the rest of my face is.)
  
  
• Along with improving my submental angle, I want to improve the appearance of my ramal area. Would bimax have a significant advantage over sliding genio in this regard, or will I need jaw implants no matter what?
  

I’m trying to set up some appointments for second opinions but there aren’t that many reputable maxfacs to talk to around here, so your input really will make the difference as I try to proceed with this. As always, your help is greatly appreciated. Thank you.

[ditterbo]

Ah you again, lol.  I didn't recognize you until the bottom of the reel.  I think medically bimax would be considered aggressive, unless you have moderate to severe OSA.  Your airway looks roughly normal though, based on the ceph.  Is the ortho you went to a run of the mill type or one that routinely works with max facs surgeons?  The latter type would tell you if your teeth are compensating for a skeletal deformity or not.

Aesthetically people would say you have room to gain from bimax, but how much more over SG is obviously very subjective and it's your face you have to live with at the end of the day.  Basically you're in the same boat as me but have a better chin bone & occlusal plane.  That occlusal plane will make things weird for bimax. You don't have much rotation possible at all, if any, yet you have a steep MPA.    A bigger jaw advancement without CCW would lengthen your face excessively.  Probably more natural to advance the jaw + maxilla a bit anyway, but who knows if aesthetically that really matters.  No idea how much a little jaw advancement + SG would look vs just an SG. I don't think SG or bimax does anything to the ramal area, except maybe a slight soft tissue tightening (don't bet the bank on that).  IMO you have a 'journey' ahead of you.

[emanresu]

Ah you again, lol.  I didn't recognize you until the bottom of the reel.  I think medically bimax would be considered aggressive, unless you have moderate to severe OSA.  Your airway looks roughly normal though, based on the ceph.  Is the ortho you went to a run of the mill type or one that routinely works with max facs surgeons?  The latter type would tell you if your teeth are compensating for a skeletal deformity or not.

Aesthetically people would say you have room to gain from bimax, but how much more over SG is obviously very subjective and it's your face you have to live with at the end of the day.  Basically you're in the same boat as me but have a better chin bone & occlusal plane.  That occlusal plane will make things weird for bimax. You don't have much rotation possible at all, if any, yet you have a steep MPA.    A bigger jaw advancement without CCW would lengthen your face excessively.  Probably more natural to advance the jaw + maxilla a bit anyway, but who knows if aesthetically that really matters.  No idea how much a little jaw advancement + SG would look vs just an SG. I don't think SG or bimax does anything to the ramal area, except maybe a slight soft tissue tightening (don't bet the bank on that).  IMO you have a 'journey' ahead of you.

Surprise, it's me . Thanks for the reply. My ortho is definitely the type that works with maxfacs, but she never mentioned anything about a skeletal deformity (but maybe I’ll email and ask) and that my bite was almost perfect besides some minor crossbite. She then referred me to the maxfac who basically said the same thing and recommended a sliding genio for my aesthetic concerns. I asked him if he thought I had biprotrusive teeth but he didn't seem to think I do. To his credit, he said he’d still do bimax, but just that it really wasn’t worth it in my case without a functional issue. It’s very strange how I just keep getting told that I have a good bite and these responses from professionals that make it seem like there isn't really any definitive problem(s), but anyone with two eyes can clearly see something weird is going on with my face.

A flat occlusal plane + steep MPA would probably mean the problem is an underdeveloped jaw? The maxfac mentioned that my chin is so recessed that I have mentalis muscle strain (which I never noticed before because I thought it was just an acne scar, woops), so it’s really starting to seem like the issue is mainly an underdeveloped jaw, and I guess there really isn’t an ideal solution to this problem besides sliding genio + jaw implants (which I really wanted to avoid because of the stories I read about them randomly getting infected a decade later). I’ve also been a mouth breather my whole life and will be seeing a myofunctional therapist soon. Maybe by actually having a proper swallowing pattern it will develop my atrophied neck muscles and perhaps raise my hyoid a bit?

The subjectivity of the situation is definitely playing a part in my concerns, and I personally would be fine with this “8 out of 10” or whatever result, but I wasn’t sure if my maxfac’s optimism was actually close to accurate or not. I’m concerned about the possibility that my maxfac is not considering all the possible effects this sliding genio could have on my face, like causing a long face or a narrow looking lower third, or creating a strangely protruding chin (See attachment. What happened there?), and I don’t fully trust that he would tell me. Unless bimax has a significant advantage over sliding genio for me, I’d like to proceed with the sliding genio as long as my face is ‘compatible’ with it, I’m just not sure if it is or not.

Also that’s interesting about jaw advancement lengthening the face. Is that because jaw advancement isn’t ‘true’ forward, but forward along the occlusal plane?


[attachment deleted by admin]

[boyo]

You need orthodontic decompensation. You need to remove teeth to make room for a large BSSO followed up with a genioplasty. That would be the long, expensive but proper way to do it.

[emanresu]

You need orthodontic decompensation. You need to remove teeth to make room for a large BSSO followed up with a genioplasty. That would be the long, expensive but proper way to do it.

Thought so. Previous camoflauge orthodontics has been my suspicion since the beginning, but neither my ortho or maxfac wanted to say that's what happened to me.

Tough call. I would personally get a BSSO at least.

Hey jawjawbinks, BTW I mentioned the biprotrusion to the maxfac but he didn’t seem to think it was a big deal. Strange considering how severe it looks from the x-ray.

You guys suggest a BSSO, but my jaws seem to line up, so wouldn't that mean I'd need bimax? None of the surgeons who perform bimax around here do CW or CCW and I still don’t fully understand how rotation is used with advancement (such as how ditterbo described) to achieve a good aesthetic outcome, so I have no idea if I need it and if I can safely proceed with jaw surgery with a local maxfac, as they obviously won’t admit if I need rotation or not. I know that CCW lowers the ramus and fills out the face more, which seems like the exact thing I need, but my occlusal plane is close to flat. Does that mean I'd only need straight advancement?

The other main issue is the fact that I have zero complaints functionally. I'd really rather avoid full-on jaw surgery if I could, and I'm still trying to determine whether or not a sliding genio will work in my case without introducing new aesthetic problems. I've been reading about facial proportions (I think I've determined that I don't need any additional verticality), but I can't find anything specifically about a how a sliding genio would look on someone with a smaller lower third like me: will it make it look narrow and non-uniform compared to the rest of my lower third? will it protrude strangely?

[attachment removed]

Or will the skin stretch out in a more normal manner?

The example attached to my previous reply looks very strange and I don't want this to happen.

[ditterbo]

LOL great morph, that quarter profile shot chin looks almost exactly like mine with a 12mm chin implant.  A pretty big problem you also have is with your eyes, btw. The lower lid sags down, scleral show or whatever it is. May reply with more general info later.

[emanresu]

LOL great morph, that quarter profile shot chin looks almost exactly like mine with a 12mm chin implant.  A pretty big problem you also have is with your eyes, btw. The lower lid sags down, scleral show or whatever it is. May reply with more general info later.

Haha thanks, I'm getting better at them. And sorry I don't mean to offend when I said it's 'weird' in the picture I posted, but rather that I feel like the chin is almost too strong for the rest of the face. But I've read that sliding genios sit a bit more naturally so I don't want to give up hope yet. Also thanks for the heads-up about my eyes, I'll definitely start looking into it. And any insight seriously means the world to me so that would be awesome!

[CCW]

Are you in Toronto? Have you seen Dr. Tocchio? I know he does CCW because I have seen blogs by his patients that clearly had it done (even if it might not suitable for your case, it's still a sign of a good surgeon). His results look good, so I'd see him.

[emanresu]

Are you in Toronto? Have you seen Dr. Tocchio? I know he does CCW because I have seen blogs by his patients that clearly had it done (even if it might not suitable for your case, it's still a sign of a good surgeon). His results look good, so I'd see him.

I am indeed! I have not seen Dr. Tocchio yet but I have my first consultation with him next month.

I previously read a post here that said Toronto surgeons are 'old school' and don't do rotations so I was feeling very discouraged that they were incompetent, but maybe that was silly of me to believe. So thank you for the recommendation. It motivated me to call Tocchio today to find out about rotations once and for all, but the nurse simply said "He does whatever is necessary." I guess that's the answer I expected to hear, lol.

With Dr. Caminiti, the conversation steered completely towards getting a standalone sliding genio, which I'm still very interested in the possibility of, but I'm definitely kicking myself for not asking about what his plans for bimax would've been.

[Lefortitude]

The previous advice on the long, expensive but proper way is correct.  However, if you want to cut that down considerably, a chin wing and a haircut will likely do the trick cosmetically.  you would have to go to europe, but its probably worth it.  If i was in your shoes (and i am), thats the direction id be going (and i am). 

[emanresu]

The previous advice on the long, expensive but proper way is correct.  However, if you want to cut that down considerably, a chin wing and a haircut will likely do the trick cosmetically.  you would have to go to europe, but its probably worth it.  If i was in your shoes (and i am), thats the direction id be going (and i am). 

Interesting, may I ask who is performing your surgery? I ask because I thought I remembered reading somewhere (I can't find the thread now) that either Triaca or Zarrinbal don't accept overseas patients. I also read that in some cases they sometimes offer the option of using Bio-Oss instead of hip grafts. Do you know what cases allow this?

Also since you have a similar case to me, do you think the concerns I described in the morphs above have any merit if I were to proceed with a sliding genio?

[JimmyTheGent]

You need orthodontic decompensation. You need to remove teeth to make room for a large BSSO followed up with a genioplasty. That would be the long, expensive but proper way to do it.

Do you always have to remove teeth for orthodontic decompensation?  Aren't some surgeons able to do this without extractions?