What surgical technique do I need? Images included.

[JigJaw_:/]

Hey everyone.
I've had a couple of different ortho appointments as of late. Trying to decide the best approach/plan for my outcome. I was on track for bimax surgery about 7-8 years ago, went through 2 years of adult braces, then fell through on the surgery. Since then I've had veneers put on my top 10 (big mistake), but I had chipping due to accident so it left me with an even worse vertical deficiency. I also had a chin implant placed, and was recently told by doctor it is absorbing the bone already (13 months in). Jesus, really?  I went back to my original oral surgeon , who went on to tell me that today the surgery would be "a lot of running for a little jump."  I have a very obvious shorter lower 1/3 and almost no chin, mixed with some asymmetry of the jaws and a long upper lip to go along. Now my smile is just all jacked up, and I'm left fitted with an implant that is highly annoying and has caused a ton of lower lip dysfunction. How hard would bimax surgery be for my case? I put some ceph xray images to help. Also, if I have a Class 1, is a surgery first plan all that uncommon...or are aesthetic/functionality best suited through braces first? I also have tmj pain, but my airway seems to be okay. Who are the best U.S. doctors that would focus more on aesthetics and a little functionality. I don't want to waste a bunch of time and money dishing out for consults that aren't going to benefit my long term goals. I had one ortho tell me that braces would fix my issues; was laughable. She then proceeded to offer me the most expensive plan/braces. Thanks for the help.

https://imgur.com/a/D7x8d

[kavan]

You have GOOD bone structure with basic balance of bone planes and also balance of '1/3rds'. No 'obvious shorter lower 1/3rd' on full face photo. I measured.  Red arrow points to the chin implant. It's a different shade of grey, so you have to look for it on original.

Your asymmetry is minor. If you got bi-max, there would be no room for standard 'error' from perfection where as in people who really need bi-max, the improvement from it far EXCEEDS minor symmetry imperfections that could arise. Your good bone structure does not suggest 'need' for bi-max. However, if you wanted, you could have your (silicone?) implant removed and exchanged for a bone cut genio.

The rest of your issues are soft tissue ones where the bone ISN'T such as between the cheek bones and lower jaw. eg. Some Sculptra would help fill out somewhat. Long labial ledges are fine for male. But that too is in venue of soft tissue alterations such as lip lift.

[JigJaw_:/]

Appreciate your analysis.
I'm nearly 6'1 tall, so my face just doesn't match my body. I actually sent my X-rays/imaging over to Dr. Niamtu, he seems s to be fairly well versed on the genioplasty, he's the one who told me the implant was quite malpositioioned. If the red arrow is pointing to the implant, no wonder it's giving me so many lip issues/stiffness.
Is the room for error that small in my case? I guess I'm just extremely leeerie of pulling the trigger on another chin procedure;first one has caused issues and solved nothing. Seems my smile sits way too far back in my mouth, only lately have I also been researching lip procedures,  but again...I don't want to take a short cut down a path to further complication and basically regress in treatment.
Not sure I grasp what your describing in regards to cheek bones & lower jaw, sculpta etc. ; will have a o look that up. 

[GJ]

Agree with Kavan I see no obvious deficiency in the lower 3rd.

Bones look good. Eyes are a bit close-set, so that might be giving a false illusion of the face being compact. I'd say remove the implant, go with a vertical genio if you really want to add length.

What went wrong with the veneers, by the way? I'm not a fan of those, but I like to collect mental notes/anecdotes on why.

[kavan]

Appreciate your analysis.
I'm nearly 6'1 tall, so my face just doesn't match my body. I actually sent my X-rays/imaging over to Dr. Niamtu, he seems s to be fairly well versed on the genioplasty, he's the one who told me the implant was quite malpositioioned. If the red arrow is pointing to the implant, no wonder it's giving me so many lip issues/stiffness.
Is the room for error that small in my case? I guess I'm just extremely leeerie of pulling the trigger on another chin procedure;first one has caused issues and solved nothing. Seems my smile sits way too far back in my mouth, only lately have I also been researching lip procedures,  but again...I don't want to take a short cut down a path to further complication and basically regress in treatment.
Not sure I grasp what your describing in regards to cheek bones & lower jaw, sculpta etc. ; will have a o look that up.

Looks small for bi-max but not for isolated genio to replace chin implant. Looks like you have a 'button' implant which is easiest for most docs to put in.  Did a PS put that in? Sculptra is an injectable soft tissue 'filler'. But, yes, in matters of soft tissue issues, you will need to look those up simply because here, my focus is on the bone alterations. So, soft tissue 'things' or things more in venue of PS, I don't elaborate much on.

[JigJaw_:/]

I believe it's silicone. The doctor (Fred Hackney), PS, has since taken medical retirement...so he's not exactly available for the "bone" I'd like to pick with him. I was told pre procedure it would be fixed with screws, and that it wouldn't be a button implant...but now I honestly have no firm frame of reference with which to go on.
Yes, my eyes are a bit close. Have fractured my nose several times on the ridge, so that too has given the illusion of closer set (least I think).
As for the venders, they have just created a bigger overbite, i.e. the ortho who designed  them gave them a bit more length/size to give me more tooth display. Just feels disproportioned. Nothing so much categorically -(wrong) with them. Also, my teeth were grinded down, so, it's forever; perhaps I'm just little bitter about the entire outcome. It very well might be that the impant is creating more issues than I'm currently able to grasp. Seems like the implant is gripping real close to my teeth, its created an upward curling on my bottom lip; very strange.
Don't know about the sculpta, looks like a temporary procedure of considerable replacement intervals.
So, sliding genioplasty. How much chin bone does the doctor need to be able to create/construct a nice vertical improvement. Read a little about this chin wing osteotomy procedure that seems to be gaining popularity.

[kavan]

I believe it's silicone. The doctor (Fred Hackney), PS, has since taken medical retirement...so he's not exactly available for the "bone" I'd like to pick with him. I was told pre procedure it would be fixed with screws, and that it wouldn't be a button implant...but now I honestly have no firm frame of reference with which to go on.
Yes, my eyes are a bit close. Have fractured my nose several times on the ridge, so that too has given the illusion of closer set (least I think).
As for the venders, they have just created a bigger overbite, i.e. the ortho who designed  them gave them a bit more length/size to give me more tooth display. Just feels disproportioned. Nothing so much categorically -(wrong) with them. Also, my teeth were grinded down, so, it's forever; perhaps I'm just little bitter about the entire outcome. It very well might be that the impant is creating more issues than I'm currently able to grasp. Seems like the implant is gripping real close to my teeth, its created an upward curling on my bottom lip; very strange.
Don't know about the sculpta, looks like a temporary procedure of considerable replacement intervals.
So, sliding genioplasty. How much chin bone does the doctor need to be able to create/construct a nice vertical improvement. Read a little about this chin wing osteotomy procedure that seems to be gaining popularity.

It looks like a silicone button implant placed kind of above the level of the pogonian or let's just say; not along the base border of the chin but higher than that and high enough to make the lip-chin fold less 'curvey' than it should be. Silicone buttons are often just sewn into a pocket. Screws usually show up as radio-opaque and i don't see any.

Sculptra is not 'perm' filler but it can plump out soft tissue where you could use it.

'how much' as to chin cuts and movements is a matter of MEASURE and planning. 

Now, this is not meant to be a personal 'rec' from me but I can tell you that in the Dallas area (where the PS who put in your chin implant is/was), Craig Hobar is a better PS who also can do genios.

As to 'popularity' of something, that is a function of MULTIPLE parties/patients--as opposed to ONE party making up a bunch of screen names to promote something. So for a chin wing, you better make damned sure you are looking at a number of unique individuals and not just promo content from one party (who has been banned here for deceptive promos).

[MyTimeIsNow]

I don't see you aesthetically benefiting from bimax in non-trivial way.

Consider following procedures for aesthetics improvement:
Eyebrow transplant
Rhino for correcting asymmetric nose - I'm not knowledgeable about rhinos, so I'm not sure if you can actually achieve significant improvement and it's a procedure with high revision rates
Maybe some kind of ottoplasty as you do have weird shaped ears towards the top
Get a tan

There is no way I can advocate bimax for aesthetic reasons to you based on benefits: cost and risks ratio unless you have significant functional issues (sleep apnea, etc.).

[kavan]

.....
the impant is creating more issues than I'm currently able to grasp. Seems like the implant is gripping real close to my teeth, its created an upward curling on my bottom lip; very strange. .....

Remember I mentioned it was placed high...well, it's  close to your tooth roots.

[ditterbo]

Remember I mentioned it was placed high...well, it's  close to your tooth roots.

Was going to say this but yep.  That area's not supposed to house a chin implant, and is why you are getting such quick bone erosion.  Soon that may erode into your teeth roots and you'll have a much bigger problem (I don't know specifics anymore though, maybe risking extractions/infection; google it).  IMO get rid of that thing asap. It's pretty small from the looks of it too, maybe 3-4mm.  Shouldn't be too big a deal though I'm guessing he went through the mouth to place it that high. Only trade off is you'll get back to mostly the old labiomental fold you used to have, however acute that was.

Heck I think you can see the bone erosion pretty obviously in that x-ray.

[PloskoPlus]

I don't think you have a short lower third, I think it's an illusion courtesy of the long midface. A couple of guys here have had lip lifts with very good results. Might be something for you to consider... But shortening the lip may make the nose look longer. It may also produce lip incompetence. You also appear to have a cant to your mouth. This may be hard to fix. You could get CW rotation (maxillary downgraft, lower jaw advancement) for more tooth show, longer lower third, but I think you won't like your face being longer. I wouldn't do it.

[ditterbo]

I don't think you have a short lower third, I think it's an illusion courtesy of the long midface. A couple of guys here have had lip lifts with very good results. Might be something for you to consider... But shortening the lip may make the nose look longer. It may also produce lip incompetence. You also appear to have a cant to your mouth. This may be hard to fix. You could get CW rotation (maxillary downgraft, lower jaw advancement) for more tooth show, longer lower third, but I think you won't like your face being longer. I wouldn't do it.

I sense a bit of a fishbowl affect going on in most of his face shots, which make his mid-face appear even longer. The smile shot looks pretty good/balanced but it's still only ~3 feet from his face. Needs to be 5/6, IIRC, to avoid fishbowling.

[PloskoPlus]

I sense a bit of a fishbowl affect going on in most of his face shots, which make his mid-face appear even longer. The smile shot looks pretty good/balanced but it's still only ~3 feet from his face. Needs to be 5/6, IIRC, to avoid fishbowling.

True. But I think these close shots don't make a compact midface look long, while they do make a long midface look even longer than it is... If that makes sense.

[kavan]

I don't see fish bowling. You see that more in CONVEX profiles than balanced ones. He has the latter. His face can be divided into '1/3rds' so his bottom 1/3rd= his middle 1/3rd. However, he does have more length than width with respect to the yellow and red lines. But there is no balance for that. Nor is it really a cosmetic 'defect'.

[JigJaw_:/]

A lot to think about.
Haha, what the heck is an eyebrow transplant? I'm obviously being sarcastic, but...I wasn't even aware that existed. I see chicks get them painted on all the time, never really seems to pan-out; maybe I'll just trim for the time being....sit back and see if science brings anything new to the table.
Rhinoplasty is already on the radar, but will have to wait The chin-implant is certainly at the top of my concerns, not just the cosmetic aspect. To be quite honest, I was viewing the images (just had the ceph a week ago) thinking that the implant was placed correctly, and that I merely had some type of nerve issue going on coupled with the fact it was a button implant. Reason being, I figured the "step down" towards my teeth roots was created by the implant itself. Does that make any sense? However, certainly DOES NOT make sense for me to be experiencing pain near the roots. Suddenly extra concerned about more time elapsing. I was planning on taking a trip to Virginia to get a genioplasty consult (implant removal), but I went ahead today and scheduled with Dr. Sinn for a couple of weeks from now.
Really wish there was a way to get this PS doctor to pay (financially) for the work he DID NOT do.  The same doctor actually-also performed an open Rhinoplasty, hard to tell bc nothing changed bc my nose looks exactly the same only more inflammation remaining.
I'm not sure what a lip-can't  issue entails. I'm sure it's on the web. I'm planning to discuss lip lift possibilities with the same doctor but I have no idea if that's in his wheelhouse.
I appreciate all the ideas and/or analysis. Does definitely help me gain perspective.