CCW rotation effect on lips and philtrum

[some1afterall]

He did tell me he would take about 5mm off the chin (with the genioplasty) and we had a total of 10-11mm to make up for (with the lip incompetence).

[some1afterall]

Is this a typical Gunson surgical plan? CCW and down grafting?

[kavan]

I can't opine in terms of 'risk'. Only the doctor doing the surgery can give you a better idea of risk relative to in HIS hands.

The plan is 'typical' in the sense that he would do a significant posterior downgraft for the type of CCW needed to maximize the the extent of the lower jaw advancement and to also shorten the chin so the face does not cast as 'long' or 'too long' in frontal view. He also gives more 'flip' to the upper lip with the change in angle to the front teeth which tends toward more support of it as he told you and also to visually shorten the philtrum. Observe the diagram and you should see that.

It is best to cast your focus on observing the contour changes that can be seen on the displacement diagram and not get caught up in isolated numbers because all the isolated measures associated with the displacements are part of the WHOLE contour change which is seen outlined in red. Hence, better to hone one's powers of observation when there is a contour diagram to observe than to get caught up (and perhaps eventually confused) by all the different measures for each thing to be displaced.

[GJ]

Can you post a larger image of the ceph or email it to me?

It's small on my monitor. From what I can see you are still 10mm recessed. This is typical of unskilled surgeons who don't understand rotation.

[some1afterall]

Yes, he did talk about improving the lip/philtrum area.

I trust that Gunson is a more skilled surgeon than the one who performed my original surgery.

[GJ]

Okay much easier to see now.

You can see the entire complex is rotation CCW. So as the lower jaw swings forward and up, the upper jaw the upper jaw is rotating along an invisible fulcrum. Basically the back of the upper jaw comes down, and the front moves sightly up (this might move forward, too depending on the bone and how the teeth are placed).

In general, I'd say prepare for a larger lower jaw, shorter face, and with regard to your question about the philtrum area, I'd guess that area gets more "sunken" in. That isn't a guarantee to happen, but as the upper jaw rotates you could theoretically lose some support there. This is why Dr. Gunson grafts the area. Almost everyone I have spoken with says those grafts don't do much. But then again, we can't see those patients without the grafts to compare. In poor lighting that shows depth of lines in the face you might notice a worsening in the smile line region, IMO. The lip support should improve.

Overall, it should be an improvement over the current situation, but likely will have a few issues mentioned above that you have to weigh. There are also the increased risks of revision to consider.

[PloskoPlus]

By grating, you mean onlay HA grafts?

[GJ]

By grating, you mean onlay HA grafts?

Yes.

[PloskoPlus]

Yes.

I've seen him put them over the plates... Surely that'd make any revision a lot harder.

[some1afterall]

Okay much easier to see now.

You can see the entire complex is rotation CCW. So as the lower jaw swings forward and up, the upper jaw the upper jaw is rotating along an invisible fulcrum. Basically the back of the upper jaw comes down, and the front moves sightly up (this might move forward, too depending on the bone and how the teeth are placed).

In general, I'd say prepare for a larger lower jaw, shorter face, and with regard to your question about the philtrum area, I'd guess that area gets more "sunken" in. That isn't a guarantee to happen, but as the upper jaw rotates you could theoretically lose some support there. This is why Dr. Gunson grafts the area. Almost everyone I have spoken with says those grafts don't do much. But then again, we can't see those patients without the grafts to compare. In poor lighting that shows depth of lines in the face you might notice a worsening in the smile line region, IMO. The lip support should improve.

Overall, it should be an improvement over the current situation, but likely will have a few issues mentioned above that you have to weigh. There are also the increased risks of revision to consider.

Thanks for your reply. In regards to CCW and perceived negative aesthetic outcomes:

Things I don't like right now are long flattened philtrum, long chin, lack of lip support.
Things I do like amount of tooth and gum show when I smile, strong cheekbones.

I definitely am hesitant to move forward with a surgery that could possible age me. I have genetically downturned eyes with creased eyelids and lots of crows feet at 32, so aging of smile line area sounds meh.

Also I'm not sure what you mean by philtrum area "hollowed", I thought that CCW would help create more supported lips and a shorter more attracted, slightly curved inward philtrum... more like (

[some1afterall]

I've seen him put them over the plates... Surely that'd make any revision a lot harder.

If I decide to go through with this surgery it will be my last time.

So the other angle would be what about just fixing the genioplasty? It doesn't fix everything but it would be a big winner in the aesthetics department as my long chin is the thing I dislike the most. Dr Deschamps Braly in SF will do a vertical reduction genioplasty with upward angling... ughhh... maybe I can just find someone to take the plate out.

[kavan]

Thanks for your reply. In regards to CCW and perceived negative aesthetic outcomes:

Things I don't like right now are long flattened philtrum, long chin, lack of lip support.
Things I do like amount of tooth and gum show when I smile, strong cheekbones.

I definitely am hesitant to move forward with a surgery that could possible age me. I have genetically downturned eyes with creased eyelids and lots of crows feet at 32, so aging of smile line area sounds meh.

Also I'm not sure what you mean by philtrum area "hollowed", I thought that CCW would help create more supported lips and a shorter more attracted, slightly curved inward philtrum... more like (

If you observe the diagram and how the lips relate to the upper teeth, it shows less upper teeth show.

[PloskoPlus]

If you observe the diagram and how the lips relate to the upper teeth, it shows less upper teeth show.

... At rest.

[PloskoPlus]

The CCW rotation will create (optically) more posterior jaw height and width making your face look more oval.  This, together with shortening genioplasty should make the face less long and more balanced.  Since you have lip incompetence and this plan should address it, it's probably worth pursuing.  But at the end of the day, you have to make the call.  The alternative of just a 10 mm reduction genioplasty doesn't sound great to me.  You will end up complaining that your lower third is now too small.  But then again, I'm not a fan of genioplasties.  They are overdone 90% of the time because most surgeons are incapable of creating enough lower jaw advancement.  Genioplasty should be just the icing on the cake, not half of the cake.

[some1afterall]

I’m going to follow up with Dr Karas. He ordered my a 3DCT TMJ work up to further evaluate my case. He’s less bells and whistles than Dr Gunsom, but he did a great job with Ashley’s (Lyra) complex case and I liked him a lot. Great listener, seems cautious and thorough. I’d like to get a better feel for what his surgical plan would entail.

Plosko-thanks for your feedback. You’re probably right. After all this I’m not a fan of genioplasty’s either. I liked my pre-genioplasty cover up face much better. In retrospect, I should’ve never gone back for the genioplasty add on.