Risk and stability of down-graft to improve tooth-show

[eranthe]

Hi, first time poster. 

I began with an acute Class II with VME.  August 2014 I had a SARPE and October 2015 I had a Le Fort and BSSO which left me with good tooth-show and lip competency but a mid-line markedly off to the left, a deviated septum and crooked nose.  In 2016 I had a revision Le Fort to try and centre the mid-line and straighten the nose.  The surgery improved the mid-line position somewhat, however, for some reason my surgeon removed of a LOT of VME.  This left me with noticeable mid-face deficiency so my mid-face appear short and flat, my nose is now too long and wide for my face (my surgeon does not use alar cinch), and I have zero tooth-show at rest and perhaps 2mm in a full smile (which will no doubt revert back to -2mm when the braces that are holding my top lip up are removed). 

I realize aesthetic changes are to be expected (I had the surgery for sleep apnoea which has somewhat improved but not as much as I hoped as I don't feel my mandible was brought forward far enough to improve either breathing or profile), the combination of asymmetry, wider longer nose and lack of any tooth-show have made me look old, tired, toothless and angry and it has been extremely distressing.  I feel sad every time I look in the mirror and have become depressed and anti-social.  I realize attractiveness is subjective, but honest friends have confirmed the disappointing changes.

For the last year my surgeon has been trying to discourage me from a down-graft, pushing me towards plastic surgery.  He has been focusing on the risks of down-grafting the maxilla (possible non-union; lack of blood supply to the face) and the negative affects (accompanying backward rotation of the mandible; relapse).  Whilst I understand it is an inherently risky and notoriously unstable procedure, and whilst I am angry that I must now risk further backwards rotation of the mandible when it was not brought forward far enough originally, I just don't think a plastics approach will work.  I feel as though a rhinoplasty and lip lift will concentrate my features in the centre of my face, further shorten my face, accentuate the asymmetry and leave me with lip incompetency and mentalis strain.

Finally in the last few days my surgeon has agreed to a revision down-graft in March.  Whilst this is a relief, I'm now left feeling anxious about the potential risks of this surgery.  So I'm hoping to connect with others who have undergone a down-graft (and also the harvesting procedure from the iliac crest which frightens me) who may be able to offer some honest insight into the procedure, recovery, risks, stability and (hopefully) achievements post-op.  It would be great to hear/see some positive results from this procedure as my team have really been focusing on the neg aspects.

Thanks

[ditterbo]

You're screwed if you go back to your old doctor.

[kavan]

Hi, first time poster. 

I began with an acute Class II with VME.  August 2014 I had a SARPE and October 2015 I had a Le Fort and BSSO which left me with good tooth-show and lip competency but a mid-line markedly off to the left, a deviated septum and crooked nose.  In 2016 I had a revision Le Fort to try and centre the mid-line and straighten the nose.  The surgery improved the mid-line position somewhat, however, for some reason my surgeon removed of a LOT of VME.  This left me with noticeable mid-face deficiency so my mid-face appear short and flat, my nose is now too long and wide for my face (my surgeon does not use alar cinch), and I have zero tooth-show at rest and perhaps 2mm in a full smile (which will no doubt revert back to -2mm when the braces that are holding my top lip up are removed). 

I realize aesthetic changes are to be expected (I had the surgery for sleep apnoea which has somewhat improved but not as much as I hoped as I don't feel my mandible was brought forward far enough to improve either breathing or profile), the combination of asymmetry, wider longer nose and lack of any tooth-show have made me look old, tired, toothless and angry and it has been extremely distressing.  I feel sad every time I look in the mirror and have become depressed and anti-social.  I realize attractiveness is subjective, but honest friends have confirmed the disappointing changes.

For the last year my surgeon has been trying to discourage me from a down-graft, pushing me towards plastic surgery.  He has been focusing on the risks of down-grafting the maxilla (possible non-union; lack of blood supply to the face) and the negative affects (accompanying backward rotation of the mandible; relapse).  Whilst I understand it is an inherently risky and notoriously unstable procedure, and whilst I am angry that I must now risk further backwards rotation of the mandible when it was not brought forward far enough originally, I just don't think a plastics approach will work.  I feel as though a rhinoplasty and lip lift will concentrate my features in the centre of my face, further shorten my face, accentuate the asymmetry and leave me with lip incompetency and mentalis strain.

Finally in the last few days my surgeon has agreed to a revision down-graft in March.  Whilst this is a relief, I'm now left feeling anxious about the potential risks of this surgery.  So I'm hoping to connect with others who have undergone a down-graft (and also the harvesting procedure from the iliac crest which frightens me) who may be able to offer some honest insight into the procedure, recovery, risks, stability and (hopefully) achievements post-op.  It would be great to hear/see some positive results from this procedure as my team have really been focusing on the neg aspects.

Thanks

If the salient problem is lack of upper tooth show, it does seem TOO MUCH (pain, suffering and risk) to get yet another maxfax surgery where as a LL will give you more tooth show. A lip lift is not going to leave you with lip incompetency and mentalis strain.

[Framboise]

Hi eranthe.

Ditterbo is absolutely right.

I've seen different surgeons, an several times a downgraft was offered to me. Nobody told me about the risk of instability.
Maybe you're a difficult case, regarding your past jaw surgeries.
Or, your surgeon has not enough skills to do this, which is possible because he has already botched you.
How much mm downgraft to you need ?

My advice is to have at least 2 others surgeons'opinion.

[ITALIA]

Is a downgrafting inherently more risky than other bone cutting surgeries??

Dr defranq seems to have a number of examples on his website, you may want to talk with him.

[eranthe]

Thanks for the replies. 

Ditterbo I'm screwed either way.  I'm a public patient who had this surgery for functional reasons (breathing and sleep apnea).  My treating hospital is based on my residential postcode, and my surgeon is the head of maxfac at that hospital.  I simply don't have the money to pay for revision surgery privately with a new surgeon. 

Kavan whilst the salient problem is tooth-show, my occlusion also feels awkward and constricted since the revision lefort when I was further impacted.  I suspect he also did some degree of CCW rotation as my upper teeth are now very upright and seem to rest in mid air when my mouth is closed (as in my teeth don't meet).  When I bite it feels as though I have to raise my lower teeth quite a bit to make contact, and when I do my top teeth sit on top of my bottom teeth, rather than sliding over them comfortably.  I have to almost retract my mandible slightly to allow my upper teeth to slide over the lower teeth.

In relation to the rhinoplasty/lip lift option (which I would love to be able to opt for), when I lift my top lip up even a couple of mm's to mimic the subtlest lip lift, I have to force my lower lip up to meet my top lip, it forces my lips into a downward grimace and causes my chin to dimple.  As it is, after all these surgeries, I sleep with my mouth hanging open. Also, these surgeries have left me with asymmetry and I have lost a LOT of mid-face length ... a shorter face accentuates those asymmetries.

Framboise, yes I know Ditterbo is right ... but I have no other options but to stay like this or trust that my surgeon gets it right this time.  If I had money I would be taking Italias advice and flying to Dr Defranq (I'm in Australia)   During a frank conversation, my surgeon admitted it was a suboptimal aesthetic outcome and noted that he was more of a functional surgeon and would like to involve the hospitals plastics team this time around to help with aesthetic elements etc so maybe that will help.  I do sense he feels a little out of his depth with my case.

Italia, is down-grafting inherently more risky?  I really don't know, that is what I am here to research.   This is what my surgeon and team are telling me, but I also suspect they are trying to steer me in the direction of plastic surgery as this is all a bit of a headache for them now.  As you say, there are examples of down-grafting on many websites, so people must be having them successfully - and I'd love to find those people.  I just want to make a sensible and informed decision based on what is right for me, not what is convenient for my surgeon.  Things might be crap now, but they will be a whole lot crapper if I end up with a bad plastic surgery outcome on top of all this ...

[some1afterall]

Sorry to hear about your dissatisfaction with your jaw surgeries I can empathize with having high expectations pre-surgery that were not met.

Has anyone here had surgery with Dr Defranq? Is it more affordable to have surgery done in Europe?

[eranthe]

Thanks, although I don't think I had unrealistically high expectations.  There are fairly standardized facial esthetic parameters ... what I have been left could have been avoided.

[kavan]

Thanks for the replies. 

Ditterbo I'm screwed either way.  I'm a public patient who had this surgery for functional reasons (breathing and sleep apnea).  My treating hospital is based on my residential postcode, and my surgeon is the head of maxfac at that hospital.  I simply don't have the money to pay for revision surgery privately with a new surgeon. 

Kavan whilst the salient problem is tooth-show, my occlusion also feels awkward and constricted since the revision lefort when I was further impacted.  I suspect he also did some degree of CCW rotation as my upper teeth are now very upright and seem to rest in mid air when my mouth is closed (as in my teeth don't meet).  When I bite it feels as though I have to raise my lower teeth quite a bit to make contact, and when I do my top teeth sit on top of my bottom teeth, rather than sliding over them comfortably.  I have to almost retract my mandible slightly to allow my upper teeth to slide over the lower teeth.

In relation to the rhinoplasty/lip lift option (which I would love to be able to opt for), when I lift my top lip up even a couple of mm's to mimic the subtlest lip lift, I have to force my lower lip up to meet my top lip, it forces my lips into a downward grimace and causes my chin to dimple.  As it is, after all these surgeries, I sleep with my mouth hanging open. Also, these surgeries have left me with asymmetry and I have lost a LOT of mid-face length ... a shorter face accentuates those asymmetries.

Framboise, yes I know Ditterbo is right ... but I have no other options but to stay like this or trust that my surgeon gets it right this time.  If I had money I would be taking Italias advice and flying to Dr Defranq (I'm in Australia)   During a frank conversation, my surgeon admitted it was a suboptimal aesthetic outcome and noted that he was more of a functional surgeon and would like to involve the hospitals plastics team this time around to help with aesthetic elements etc so maybe that will help.  I do sense he feels a little out of his depth with my case.

Italia, is down-grafting inherently more risky?  I really don't know, that is what I am here to research.   This is what my surgeon and team are telling me, but I also suspect they are trying to steer me in the direction of plastic surgery as this is all a bit of a headache for them now.  As you say, there are examples of down-grafting on many websites, so people must be having them successfully - and I'd love to find those people.  I just want to make a sensible and informed decision based on what is right for me, not what is convenient for my surgeon.  Things might be crap now, but they will be a whole lot crapper if I end up with a bad plastic surgery outcome on top of all this ...

Well, having a lip lift would not result in (lower) lip incompetence which is what you are describing. But it does sound that if you have to force your lower lip to meet your upper lip, you ALREADY have lip incompetence. That's a function of how the chin lines up with the lower lip. Shortest path is close to a straight vertical line such that a vertical line dropped from lower lip has the chin close to it and NOT too diaganally oriented behind or forward to that imaginary line.

Since one of your problems is you feel your lower jaw was not brought forward enough, it would follow your chin might be too far back, especially coupled with the complaint of lip incompetence and NO MENTION of genioplasty with either of your surgeries.

BASED on your descriptions, it sounds like an advancement genioplasty would help and also allow for the lip lift. Perhaps explore that option. Also ask if having veneers to lengthen the teeth is an option to compensate for the 2ncd revision surgery which left you with little tooths show.

It kind of sounds like your maxfax hesitates to do a 3rd cut through the maxilla but is SHIFTING all the risk to the act of getting a down graft. In terms of people who do get downgrafts, WHEN DONE by docs who are good at doing them, they can be stable.

I don't think the real issue here is 'stability of a downgraft'. I think it's more of a matter of a 3RD CUT to the maxilla whether or not it's for a downgraft.

[Framboise]

Kavan,
I'm not sure a new BBSO would solve the problem since
 

I have to almost retract my mandible slightly to allow my upper teeth to slide over the lower teeth.

Isn't rather the upper jaw which is not long enough ?

The problem with the lips seems contradictory though....
I believe that lip incompetency is due to the maxillary which has lost his vertical dimension.
Facelift dentistery costs an arm ( french expression sorry) and it's not certain that it would change something to lip position.  But maybe I'm wrong... If good results are possible, you have to beable to pay 10 000 dollars at least. (I had a proposal for that)


Eranthe, I don't know if your bones can endure a third surgery and Kavan's advices are relevant regarding to this aspect.

I'm in a difficult situation too, and I need a down graft but I'm taking my time because a bad surgery can worsen things.

PS : I saw Defrancg and he is the best so far (th most human and he listens !!!) I've chatted with a guy who have had a revision surgery with him and he is satisfied

[kavan]

Kavan,
I'm not sure a new BBSO would solve the problem since ...

Well, I didn't say it would.

Isn't rather the upper jaw which is not long enough ?

OP is saying too much removed in revision surgery which resulted in lack of tooth show.

The problem with the lips seems contradictory though....
I believe that lip incompetency is due to the maxillary which has lost his vertical dimension.

Lip incompetency is basically from straining the chin muscle when lifting up the lower lip. It does not arise from a short maxilla. It arises from the orientation of the chin bone relative to the lower lip. I explained that in my post.
 

Facelift dentistery costs an arm ( french expression sorry) and it's not certain that it would change something to lip position.  But maybe I'm wrong... If good results are possible, you have to beable to pay 10 000 dollars at least. (I had a proposal for that)

Not sure where 'face lift dentistry' comes in here. Having the upper teeth elongated for more tooth show is not defacto 'face lift dentistry'.

Eranthe, I don't know if your bones can endure a third surgery and Kavan's advices are relevant regarding to this aspect.

Perhaps there are language difficulties in recognizing the relevance of the rest of it?  None the less, the OP would be better served by looking for feedback from people who have had their maxilla cut into 3X to see how that worked out for them.

I'm in a difficult situation too, and I need a down graft but I'm taking my time because a bad surgery can worsen things.

PS : I saw Defrancg and he is the best so far (th most human and he listens !!!) I've chatted with a guy who have had a revision surgery with him and he is satisfied

Yes. Good idea to take one's time.

[Framboise]

 Kavan :    Yeah sometimes I misunderstood stuffs !

Well, I talked about facelift dentistery because it functions with veneers helping to restaure the vertical dimension. It's not just mere veneers aiming at lenghtening teeth, it also reestablishes a good occlusion. As eranthe was descibing issues with his occlusion, I thought you were talking about that.

Since one of your problems is you feel your lower jaw was not brought forward enough

...
indeed you talk about a genio just after and not a bsso.

I didn't know that genio had a function, I thought it was just something do for aesthetical reasons.
(In my case, one surgeon told me that my chin should me moved backward while another said it should be moved forward after surgery.... So I'm a little confused about that, still don't know what's the point. But that's another subject.)

Anyway, I'm sorry for you eranthe and I hope you will find a solution

[kavan]

Kavan :    Yeah sometimes I misunderstood stuffs !

Well, I talked about facelift dentistery because it functions with veneers helping to restaure the vertical dimension. It's not just mere veneers aiming at lenghtening teeth, it also reestablishes a good occlusion. As eranthe was descibing issues with his occlusion, I thought you were talking about that.
...
indeed you talk about a genio just after and not a bsso.

I didn't know that genio had a function, I thought it was just something do for aesthetical reasons.
(In my case, one surgeon told me that my chin should me moved backward while another said it should be moved forward after surgery.... So I'm a little confused about that, still don't know what's the point. But that's another subject.)

Anyway, I'm sorry for you eranthe and I hope you will find a solution

No problem. Hope I explained some stuff.

[ditterbo]

If your doctor screwed up the first time to the extent you described, and you have no other doctor choices, you're probably better off doing nothing at all from a max facs perspective.

[PloskoPlus]

If your bite fits (and maybe even if it doesn't), you may have trouble finding another surgeon in Australia to revise your surgery.  "Go back to your surgeon" is the standard answer.  Directing you to plastic surgeons after your surgery is also the norm.  IOTW, standard procedure in Australia is:

* Withhold information (detailed surgical plans, even cephs) - a good patient is an ignorant one.  Say something in passing about potential permanent numbness (it'll certainly be in the consent form), but certainly say nothing about potential aesthetic downsides. "Anything I'll do is an improvement" is implied.

* Make the bite fit with the simplest laziest surgery possible - no down grafting ("it's unstable!", although some will do down grafting for short face syndromes), certainly no CCW rotation with posterior down grafting. I have not seen your pre-op ceph, but I suspect you probably should have had less anterior impaction and some posterior down grafting to affect the same amount of CCW... But when all you have is a hammer impaction in your toolbox, you tend to overuse it.  Steep occlusal planes are hard to make look good (even more so when there is no gummy smile, so there is nothing to impact).  AFAIK, no surgeon in Australia will do CCW with posterior down grafting.

* Deny that any aesthetic issues may have been caused by their surgery - "wait till the swelling comes down", etc., etc..

* Tell you to see a plastic surgeon. "The things you're complaining about were pre-existing and unaffected by my surgery" is implied.

If you show your lower teeth when talking, you will probably end up with lip incompetence after a lip lift.