CCW rotation effect on lips and philtrum

[GJ]

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 (

Well there is no guarantee it would age you. Soft tissue issues are unpredictable, as we're told over and over.

I didn't say the philtrum would hollow. Just that it might be sunken, especially in certain light. Think about it: if the upper jaw rotates CCW that means everything that is up front is now moved more posterior. This could mean the midface area near the smile lines. I've seen people with sunken smile lines after CCW. Again, it is unpredictable and has to do with their starting point, soft tissue thickness, etc. Many variables. But it is something to weigh as possible.

[PloskoPlus]

Well there is no guarantee it would age you. Soft tissue issues are unpredictable, as we're told over and over.

I didn't say the philtrum would hollow. Just that it might be sunken, especially in certain light. Think about it: if the upper jaw rotates CCW that means everything that is up front is now moved more posterior. This could mean the midface area near the smile lines. I've seen people with sunken smile lines after CCW. Again, it is unpredictable and has to do with their starting point, soft tissue thickness, etc. Many variables. But it is something to weigh as possible.

IMO, that's infinitely preferable to a vertical or (worse) convex philtrum.

Before my surgery I asked if I'd end up with a chimp like convex lip.  The surgeon, in his usual patronising manner, dismissed the question: "6 mm of bone advancement turns into 3 mm of soft tissue advancement". Anyway, "by their deeds you shall know them".  I ended up with a monkey lip anyway.  Unfortunately I only saw his before and afters after my surgery.  All his patients got the monkey upper lip.  I've seen so many cases of chimp lip, that it's basically a given that if you don't have a flat occlusal plane to begin with and the surgeon doesn't do CCW, you WILL get a chimp lip.  It's guaranteed.  Sorry for venting... I'm just absolutely sick of needing facial hair to cover up this mess.

Provided this surgery goes well (no relapse, bite or joint issues), this surgery could be a big net win.

[haven]

What did Dr. Karas suggest to you? I got a referral to his office after Lyra suggested I speak with him over my "ailment".

[Tati]

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.

Very accurate. I know of several people, myself included, who's genios are basically there to mask a steep angle/help with projection.

Not only is it less than ideal aesthetically, but it can bring about functional problems aswell.

[GJ]

Very accurate. I know of several people, myself included, who's genios are basically there to mask a steep angle/help with projection.

Not only is it less than ideal aesthetically, but it can bring about functional problems aswell.

Yes. Relle told me many surgeons use it to mask surgical problems (e.g. not enough rotation, etc).
What functional problems do you have?

[some1afterall]

Hello friends, thank you much for all of your responses. We've created quite a lively discussion now, haven't we?

Ah yes, the chimp lip. I remember post surgery I looked like a Who, from Whoville. I think naturally if CCW is supposed to better support the upper lip, the philtrum groove should deepen/curve inward, like a (, which is a positive thing.

Dr Karas was great. He was soft spoken and listened intently to what I had to say. His exam was thorough, he ordered more imaging studies. He seems conservative, cautious. Since I was rushed into my first surgery only on "Don't worry, I do this all the time" to my many questions and concerns, I like the slow, cautious approach heading into a revision. I need the reassurance that I'm not jumping into something head first without testing the temperature.

I'm having quite a bit of TMJ and neck pain + headaches, both Gunson and Karas recommended mouth guards and/or PT to try to get that under control-something Kaiser Oakland NEVER suggested. Nope. They wanted to slap braces on me and take me to the OR, even though TMJ pain is only improved with orthognathic surgery in like 10% of patients.

Anyways, we'll see. At this point I'd say my revision is 25% function 75% aesthetics, but best believe anyone who has had a sub par jaw surgery knows that when you look bad after such a major surgery it affects your health and wellbeing - how you feel about yourself affects your health. Pyschosomatic.

So in the name of health I move forward. If anything exciting happens I'll let you'all know.

GJ what's the verdict? Are you going to make a $10/month forum subscription fee? $20/annual maybe?

[kavan]

Yes. Relle told me many surgeons use it to mask surgical problems (e.g. not enough rotation, etc).
What functional problems do you have?

Even IF or when it's not to mask surgical screw ups (like not enough CCW), sometimes, even with enough CCW, the mandibular plane can just be too high an angle and to give appearance of more CCW, the chin is slid upward and outward.

[april]

What does one do if one needs CCW for the lips/philtrum, but can't really afford to lose much tooth show?

[Tati]

Maybe both anterior and posterior downgrafts, with the posterior one being larger (amounting to ccw)? You might also need your jaw/s set back?

[Tati]

Yes. Relle told me many surgeons use it to mask surgical problems (e.g. not enough rotation, etc).
What functional problems do you have?

If I close my bite it's not long until I feel tension/pain in my joints. This is not due to genio, but the fact I suspect my jaws were over-advanced (which can cause tmj).

In order to give me a 10 mm maxillary advancement, a pair of premolars were extracted. This made my teeth show and lip support worse pre-op, and post-op the teeth show is not as good as it was before braces and I still don't have much lip support when smiling. I think it's due to a lack of vertical growth, though. I don't show any upper teeth, ever. It overall doesn't feel natural.

For reference, when I smile all you can see are my lower gums and a bit of lower teeth.

One thing that stood out post-op was how incredibly less comfortable my chin area was. My lower lip is smaller and feels like it's being pushed inward constantly. I know scar tissue and plates could be a case, but it seems like a direct consequence of a (more so) steep mandibular angle plus the chin being too long. It's uncomfortable and slightly painful.

Last but not least, where my soft tissue sits now doesn't quite add up with my bone structure and, if I smile/laugh for an extended period my nasal base area and septum begin aching. I also can't tell if some of the additional pain I experience when smiling comes from muscles or not.

[PloskoPlus]

If I close my bite it's not long until I feel tension/pain in my joints. This is not due to genio, but the fact I suspect my jaws were over-advanced (which can cause tmj).

In order to give me a 10 mm maxillary advancement, a pair of premolars were extracted. This made my teeth show and lip support worse pre-op, and post-op the teeth show is not as good as it was before braces and I still don't have much lip support when smiling. I think it's due to a lack of vertical growth, though. I don't show any upper teeth, ever. It overall doesn't feel natural.

For reference, when I smile all you can see are my lower gums and a bit of lower teeth.

One thing that stood out post-op was how incredibly less comfortable my chin area was. My lower lip is smaller and feels like it's being pushed inward constantly. I know scar tissue and plates could be a case, but it seems like a direct consequence of a (more so) steep mandibular angle plus the chin being too long. It's uncomfortable and slightly painful.

Last but not least, where my soft tissue sits now doesn't quite add up with my bone structure and, if I smile/laugh for an extended period my nasal base area and septum begin aching. I also can't tell if some of the additional pain I experience when smiling comes from muscles or not.

The idea of extracting upper teeth to create a bigger underbite to make more advancement possible sounds insane. What was the justification?

[haven]

If I close my bite it's not long until I feel tension/pain in my joints. This is not due to genio, but the fact I suspect my jaws were over-advanced (which can cause tmj).

In order to give me a 10 mm maxillary advancement, a pair of premolars were extracted. This made my teeth show and lip support worse pre-op, and post-op the teeth show is not as good as it was before braces and I still don't have much lip support when smiling. I think it's due to a lack of vertical growth, though. I don't show any upper teeth, ever. It overall doesn't feel natural.

For reference, when I smile all you can see are my lower gums and a bit of lower teeth.

One thing that stood out post-op was how incredibly less comfortable my chin area was. My lower lip is smaller and feels like it's being pushed inward constantly. I know scar tissue and plates could be a case, but it seems like a direct consequence of a (more so) steep mandibular angle plus the chin being too long. It's uncomfortable and slightly painful.

Last but not least, where my soft tissue sits now doesn't quite add up with my bone structure and, if I smile/laugh for an extended period my nasal base area and septum begin aching. I also can't tell if some of the additional pain I experience when smiling comes from muscles or not.

Could it be that they did the wrong type of genio on you? Maybe you needed one (if you really needed one at all) where they reduce the height a bit while still adding projection. I think Kavan said the same thing above.

Now OPs post has been hijacked, haha.

[GJ]

GJ what's the verdict? Are you going to make a $10/month forum subscription fee? $20/annual maybe?

I'm really not sure, but I guess I better decide soon. I like donation models because not everyone has 10/month or 20/year. The problem with it is nobody wants to give anything unless you force them. This is human nature, so I don't blame them, but it is a disappointing trait.

[some1afterall]

Hey I wanted to give you guys an update on my revision process. I've been given two revision plans with some similarities, some differences. 

Gunson proposed a plan of maxillary and mandibular advancement, with CCW, some posterior maxilla down grafting and about 5mm vertical reduction of chin.

Karas proposed a plan of maxillary and mandibular advancement and "we'll have to figure out what to do with the chin problem" as we get closer to the surgical date.

I think because Gunson has a substantial track record with consistently good aesthetic outcomes and he had an idea to address my "chin problem" right out of the box I'll end up working with his team.

Any thoughts?